Adherence to iron-folic acid supplement and associated factors among antenatal care attending pregnant mothers in governmental health institutions of Adwa town, Tigray, Ethiopia: Cross-sectional study

Background Iron-folic acid supplementation during pregnancy is among the very effective interventions to prevent iron deficiency anemia, low birth weight, and prematurity. There is a need of having recent studies on adherence to the supplement that consider the very recent interventions targeted to scale up the use of iron–folic acid (IFA) supplement. Therefore we sought to assess adherence to IFA supplement and its associated factors among antenatal care attending pregnant mothers in governmental health institutions of Adwa town. Methods Institution-based cross-sectional study was conducted among 629 antenatal care attending pregnant mothers. Systematic random sampling method was used to select the study subjects. Data were collected through face-to-face interview and chart-review. Bivariable and multivariable binary logistic regression was computed. Variables with P-value <0.05 were considered statistically significant at 95% confidence interval (CI). Result Only 40.9% (95%CI: 37.0%- 44.7%) of participants were adherent (took four or more tablets per week). Women in the age group of 25–29 years [AOR: 2.22(1.21–4.07)] had increased odds of adherence as compared to those in the age group ≥ 35 years. Women who received nutrition counseling [AOR: 4.12(2.12–8.03)] and partner support [AOR: 2.23 (1.42–3.49)] had increased odds of adherence as compared to those who didn’t receive nutrition counseling and partner support respectively. Similarly, women who had satisfactory knowledge on IFA supplement (AOR: 2.16(1.37–3.40)) had increased odds of adherence as compared to those who didn’t have satisfactory knowledge on IFA supplement. Conclusion Adherence to the supplement was low. Efforts shall be done to improve awareness of pregnant mothers about IFA supplement through targeted nutrition counseling that includes the engagement of a partner.

IFA supplement (AOR: 2.16(1.37-3.40)) had increased odds of adherence as compared to those who didn't have satisfactory knowledge on IFA supplement.

Conclusion
Adherence to the supplement was low. Efforts shall be done to improve awareness of pregnant mothers about IFA supplement through targeted nutrition counseling that includes the engagement of a partner.

Background
Maternal nutritional status during pregnancy is an important determinant factor for child health, development and well-being [1,2]. During pregnancy, there is an increased iron requirement. Such demands result in decline iron store during pregnancy and ultimately can leads to anemia [1][2][3]. Globally,38.2% of pregnant mothers are anemic and Africa contributes the higher burden which accounts for 44.6% [4].Additionally,20%of maternal mortality in Sub-Saharan Africa is indirectly attributable to anemia [5].However, in Africa 44% of anemia in pregnant mothers is amendable to iron supplementation [4].
Iron deficiency is the leading cause of anemia. Other causes of anemia among pregnant women includes deficiency of other micronutrients such as folic acid, and vitamin B-12.Additionally parasitic diseases such as malaria, and pre-pregnancy anemia contributes to the occurrence of anemia during pregnancy [6].
Iron deficiency during pregnancy is risk factor to spontaneous abortion, low weight gain, preterm delivery, low birth weight, and fetal distress which contributes to neonatal and maternal adverse health outcomes [7,8].On the other hand inadequate maternal folate status has been also associated with anemia, spontaneous abortion, stillbirth and birth defects [6][7][8].
Reducing anemia is an important component of achieving women and children's health, and the second global nutrition target for 2025 which calls for a 50% reduction of anemia in women of reproductive age [4]. Provision of iron-folic acid supplement to all pregnant women, is among the very critical interventions to reduce the burden of anemia. World Health Organization (WHO) has recommended a 6-month regimen of a daily supplement containing 60mg of elemental iron along with 400 μg of folic acid for all pregnant mothers. In areas with a higher prevalence of anemia, it is recommended that supplementation continues for three months postpartum [9].Similarly, in Ethiopia the national guideline for control and prevention of micronutrient deficiencies highlights the need of daily iron supplementation for at least 6months during pregnancy and 3months postpartum [10].The Ethiopia national nutrition program(NNP II) also set a key target to increase the number of women receiving iron-folic acid supplementformorethan90daysduring pregnancy to 40%by 2020 [11].
In Ethiopia, even though there is free of charge provision of the supplement to mothers; the prevalence of anemia is persistently increased. This can be supported by the evidences of Ethiopia demographic and health survey (EDHS) report that shows the increment of anemia prevalence among women of reproductive age group from 17% in 2011 to 24% in 2016 [12]. This increased prevalence of anemia while there is free of charge provision of the IFA supplement calls for updated study that considers the very recent interventions targeted to scale up the use IFA supplement. Thus the purpose of the current study is to assess adherence to IFA supplement and its associated factors among antenatal care attending pregnant mothers in governmental health institutions of Adwa town.

Study design and setting
Institution-based cross -sectional study was conducted among antenatal care attending pregnant women in selected governmental health facilities of Adwa town from May1 to 6 th July, 2018. In Adwa town there are 4 governmental health institutions that provide ante natal care (ANC) service for pregnant Women. This study was conducted on 3 governmental health institutions of Adwa town (1 hospital and 2 health centers), since the remained one health center was newly built and the case flow was very small. According to the last six months report, 2534pregnant women visit the government health institutions for ante natal care.

Study population and sampling procedure
The study population were all pregnant women who came for their second or above ANC visit to the governmental health institutions and previously supplemented with IFA tablets for at least one month. Pregnant women who were unable to speak, seriously ill at the time of data collection were excluded. Sample size was determined using single population proportion sample size calculation formula by assuming 95% confidence level, proportion of adherence to iron-folic acid supplement as 39.2% from study done in south Ethiopia [13],and 4% margin of error. Regarding adequacy of sample size for identifying factors associated with adherence, sample size was calculated using double population proportion formula for pertinent variables including age, counseling on IFA, knowledge on anemia and the calculated sample size was found to be less than the sample size calculated for determining the level of adherence. Hence, after adding 10% for non response final sample size of 629 was considered adequate. Study subjects were selected by systematic random sampling method every second interval. The sampling interval (K) was determined based on the quarterly ANC visit load (K = 1267/629 = 2).

Data collection and quality assurance procedures
Data were collected using structured interviewer administered questionnaire which is adopted and modified from Ethiopian public health institute national micronutrient survey questionnaire and other Literature[14 -16].The questionnaire consisted of socio-demographic factors, obstetric and gynecologic factors, iron-folic acid supplement related factors, and knowledge on IFA supplement and anemia related factors. Pre-test among 5% of the sample prior to the actual data collection was carried out in health center other than those included in the actual study. Pregnant mothers who came for their second or above ANC visit and previously supplemented with IFA tablets for at least one month were asked about their iron-folic acid supplement use practice using their recall response. Adherence to the supplement was defined as taking an iron-folic acid supplement at least 4 times per week [17,18].To assess knowledge about anemia, respondents were asked 12 questions on major causes, symptoms, and consequences of anemia during pregnancy. Respondents that correctly responded half of the knowledge questions on anemia were considered as having satisfactory knowledge on anemia [19,20].Similarly, to assess knowledge about iron-folic acid supplement, respondents were asked 16 questions. Those who correctly respondhalf of the knowledge questions on IFA supplement were considered as having satisfactory knowledge on IFA supplement [19,20].Gestational age was estimated by using last menstrual period (LMP) calculation or fundal height.
Nutrition counseling was measured by asking respondents if they got counseling on importance of IFA supplement, duration of the IFA supplement to be consumed, the possible side effects of the supplement and ways of handing the side effects of the supplement by health professional during their prior ANC visit. pregnant mothers are said they got nutrition counseling if they responded that they are counseled on the above listed issues by the health professional in the prior ANC visit, if not they are said they didn't get nutrition counseling. Partner support was measured by asking respondents whether their partner remind them to take the supplement on time and/or encourage them to continue the supplement as prescribed when they feel the side effect of the supplement. In this study use of other drug is defined as taking of any medication other than the supplement. Three trained Diploma Nurses collected the data. Two trained supervisors and the principal investigator supervised the data collection process.

Data management and analysis
Data were coded and entered into Epi-info version 3.5.1 and exported into statistical package for social sciences (SPSS) Version 24.0 software for analyses. Cross-checking and data cleaning was carried out by running frequencies of each variable. Descriptive statistical analyses such as frequencies, percentages, proportion with 95% CI have been used. Median, mean and standard deviation was also used to summarize various characteristics of the respondents. To identify factors associated with adherence to the supplement, first a bivariable logistic regression was performed. Subsequently, significant variables in the bivariable analysis (p-value < 0.2) were incorporated into the multivariable logistic regression. The goodness of fit of the final logistic model was tested using Hosmer and Lemeshow test.

Ethical consideration
Ethical clearance was obtained from institutional review committee of Axum University compressive and specialized hospital, Axum University. Permission letters was obtained from Adwa town health office. All participants were informed about the purpose of the study thereafter written consent was obtained. Confidentiality was maintained by using code numbers other than names. All pregnant women who were not taking the supplement as prescribed were counseled about consequences of anemia, importance of the supplement and ways of handling side effects of the supplement.

Socio-demographic characteristics
Six hundred twenty three (623) pregnant mothers attending ANC visit were included in the study making the response rate of 99.0%.The mean (±SD) age of the mothers was 29.0 (± 6.2) years. One hundred eighty two (29.2%) of the respondents were in the age range of 25-29 years followed by those in the age range of 30-34 years which accounts for 169 (27.1%) ( Table 1).

Obstetrics and health related characteristics of respondents
From the total respondents, 165(26.5%) were pregnant for their first time. The median current gestational age and the median gestational age during first ANC visit were 31.0 and 16.0 weeks respectively. One hundred sixty eight (27.0%) visit ANC four times and above. Additionally, 383 (61.5%) initiated ANC visit at gestational age of greater than 16 weeks (Table 2).

Knowledge and supplement related factors
Out of the total respondents, 512(82.2%) got nutrition counseling during their prior ANC visits. From the pregnant mothers who encountered health problem during their current pregnancy, 56(90.3%) of them took medication. Five hundred five (81.1%) and 188(30.2%) of the pregnant mothers had satisfactory knowledge about Anemia and iron-folic acid supplement respectively. Three hundred seven (49.3%) of the pregnant mothers experience side effects of iron-folic acid supplement (Table 3).From the pregnant mothers who experience the side effects of the supplement,240(78.2%) reports heartburn/gastritis as the commonest side effect followed by constipation and vomiting which accounts for 29(9.4%) and 26(8.5%) respectively.

Factors associated with adherence to Iron-folic acid supplement
In the bivariable analysis variables like age, family size, knowledge about IFA supplement, nutrition counseling, parity, planned pregnancy, history of stillbirth, time of initiation of ANC visit, number of ANC visit and partner support were found to have low p-values(p<0.2) and hence considered as candidate variables for the multivariable model. Ultimately, Age of the pregnant mother, knowledge about IFA supplement, nutrition counseling and partner support were remained significantly associated with adherence to the supplement in the multivariable binary logistic regression analysis. The odds of adherence among pregnant mother in the age group of 25-29 years were two times higher than those who were in the age group greater than 35 years of age [AOR(95%CI) = 2.2 (1.21-4.07]. Knowledge of pregnant mothers about IFA supplement was another factor found associated with adherence to the supplement. Compared to women who didn't have satisfactory knowledge on IFA supplement, those who had satisfactory knowledge on IFA supplement had two times higher odds of adherence to the supplement [AOR (95%CI) = 2.16(1.37-3.40)].
Similarly, nutrition counseling was a factor found associated with adherence to the supplement. The odds of adherence was 4.12 times higher among pregnant mothers who receive nutrition counseling as compared to pregnant mothers who didn't received nutritional counseling [AOR (95%CI) = 4.12(2.12-8.03)]. Adherence to iron-folic acid supplement and associated factors among antenatal care attending pregnant mothers Lastly, Pregnant mothers who had partner support to take the IFA supplement had 2.23 times higher odds of adherence to the supplement than those pregnant mothers who didn't have partner support to take the supplement [AOR (95%CI) = 2.23(1.42-3.49)] (Table 5).

Discussion
According to study done in North West Tigray, only 28.9% of pregnant women adhere to the supplement [15].However, our study reported relatively higher adherence to the supplement (40.9%) probably due to long time gap between the studies, by which the previous study done in Tigray is before 5 years so this might have made it less sensitive to the very recent interventions targeted to scale up the use of IFA supplement like improvement in creating awareness about IFA supplement through different medias. Furthermore, the observed difference might be due to difference in geographic locations by which study subjects of the above study were from rural areas which could have differences in awareness level about the supplement. Adherence to iron-folic acid supplement and associated factors among antenatal care attending pregnant mothers However, in our study adherence to the supplement was lower than the finding of studies done in different parts of Ethiopia;55.3% in Gondar [16]and 60% in Addis Ababa [18]. This might be due to difference in geographic location by which unlike our study, the respondents of the above studies were from urban areas which increases their accessibility and exposure to different medias that can contribute to improve awareness of mothers about anemia and IFA supplement. Additionally, this might be due to difference in the standard of the health facilities as the above study done in Gondar is in relatively well-organized setup (referral hospital) which could have adequate proper counseling about the supplement. The odds of adherence was 4.12 times higher among pregnant mothers who receive nutrition counseling as compared to pregnant mothers who didn't received nutrition counseling [AOR (95%CI) = 4.12(2.12-8.03)].Similar finding was found from studies done in different parts of Ethiopia: Misha district [13],Goba [19], and Addis Ababa [18].This can be explained by the role of nutrition counseling in improving awareness of the pregnant mothers on IFA supplement and possible ways of handling its side effect which enables them to take the supplement as prescribed.
Age of the pregnant mothers was also found associated with adherence to the iron-folic acid supplement. The odds of adherence among pregnant mothers in the age group of 25-29 years were two times higher than those who were in the age group of greater than 35 years [AOR(95%CI) = 2.2 (1. 21-4.07]. This finding is consistent with the finding of a study conducted in Tigray, Ethiopia [15], but not consistent with study done in India [21] and Mecha district, Ethiopia [22]. In our study most of the Primigravida were in the age range of 25-29 years which accounts about 40%. Hence the observed association might be due to experiencing pregnancy for the first time which makes them to be very cautious and eager to follow advice on IFAS to ensure the best maternal and fetal outcome as compared to pregnant mothers ageing greater than 35 years. This study revealed that, pregnant mothers who had partner support to take IFA supplement had 2.23 times higher odds of adherence to the supplement than those pregnant mothers who didn't have partner support to take the supplement [AOR (95%CI) = 2.23 (1.42-3.49)]. This result is consistent with a study conducted in Bench Maji Zone, Ethiopia [23].The possible reason for this association could be due to the role of partner in reminding the pregnant mother to take the IFA supplement and giving support when they feel discomfort because of the side effects of the drug.
Knowledge of pregnant mothers on IFA supplement was also found associated with adherence to the supplement. Compared to women who didn't have satisfactory knowledge on IFA supplement, those who had satisfactory knowledge on IFA supplement had two times higher odds of adherence to the supplement [AOR (95%CI) = 2.16(1.37-3.40)]. This finding is consistent with studies done in Kenya [24],Goba district, Ethiopia [19].This could be due to pregnant mothers with satisfactory knowledge on IFA supplement might be aware of the consequences of iron and folic acid deficiencies on the maternal and fetal outcome which increases their practice to manage the side effects of the drug. This enables them to stick to the recommendation of health professionals. The limitation of this study includes that electronic and pills counting method of measuring number of iron-folic acid up takes were not used, as they are expensive and not available. Moreover, adherence to the supplement is simply determined by a self-report mechanism (the women's response). This might affect the actual adherence to the supplement.

Conclusion
Adherence to iron-folic acid supplement was low. Age of the pregnant mothers, knowledge about IFA supplement, nutrition counseling and partner supports were significantly associated with adherence to iron-folic acid supplement among the respondents. Therefore this study indicates the need for implementing and strengthening efforts to increase the awareness of pregnant mothers about the iron-folic acid supplement and anemia.