The objective of this study was to assess utilization and compliance with iron supplementation and predictors among pregnant women. The overall utilization of iron supplementation during pregnancy was low, with a relatively high level of compliance with the supplements. Maternal formal education, knowing anemia and the importance of iron supplementation during pregnancy, not experiencing side effects related to iron tablets, and getting iron for free have positively influenced compliance with iron supplementation during pregnancy. On the other hand, having high/medium wealth quintiles and being visited by urban health extension workers were negatively associated with compliance with iron supplementation during pregnancy.
Accordingly, of pregnant women who were given iron supplements, 46.7%, 33.9%, 18.2%, and 1.1% received iron supplements for 30 days, 31–60 days, 61–90 days, and more than 90 days, respectively. This study’s finding was argued with a study conducted in Ethiopia [18]. However, fewer than one in twenty pregnant women (3.5%) took the supplements for more than 90 days. Besides, the utilization of iron supplementation was disappointingly low, as only 17.3% of women took the supplements during their most recent pregnancy in the preceding 5 years, and only 0.4% were supplemented for 90 or more days [12]. This could be due to the difference in the educational status of respondents and access to iron supplements.
In this study, the overall compliance rate of iron supplementation during pregnancy was found to be 92.4%. The current finding was higher than many previous reports in Ethiopia, such as the compliance rate, which varied from 60-63.6% in Addis Ababa [30, 40, 41], 87.6% in Ethiopia [35], Dire Dawa [42], Shalla District [43], 43.4% Dilla town [44], 38.3% Hadassah [26], 51.4% Burin district [45], 52.9% Debbie [46], 28.1% Denbiya District [34], 28.7% Lay Armachiho [29], 55% Gondar [47], 47.6% Aykal town [28], 44% Debre Tabor [48], 43% Wollo [49] and 74.9% in four regions of Ethiopia [18], 67.6% Simada district [50], 52.8% Debay Tilat Gen district [51], 37.2% Northwestern zone of Ethiopia [33], 55.5% Debre Markos town [52], 40.9% in Adwa town [53], and meta-analyses, 46.15, 46.1, 41.38 and 43.63% [54–57]. The present finding was also higher than many others, for example, a meta-analysis in SSA [58], Uganda [59], Kenya [60], Nigeria [22], Northwest Tanzania [61], Northern Tanzania [62], 22 Sub Saharan African countries [21], Niger [63], West Iran [64], Cambodia [32], Nepal [65, 66], India [67], and Sri Lanka [68]. Likewise, the current finding was higher than the study finding conducted in a high-income country (HIC) in which the compliance rate was 85% in Sweden [69]. However, the current finding was lower than the report from South Africa [24] in which the compliance rate was 93%. This might be because of variation in the educational status of respondents and self-reporting as education increases pregnant women’s ability to easily access information dissemination and media outlets.
Educated pregnant women were 4.45 times more compliant with iron supplementation during pregnancy as compared to illiterate pregnant women. The current finding was agreed with studies conducted in Addis Ababa [40], Denbiya District [34], Lay Armachiho [29], Debre Markos Town [52], a meta-analysis in Ethiopia [56]. This might be because educated pregnant women were more likely to appreciate the benefits of iron supplementation in pregnancy and hence more likely to comply with the prescription. Nonetheless, the present study’s results were claimed by a study conducted in Ethiopia [18]. Similarly, the current study was supported by a study conducted in Burji Districts [45]. The possible explanation could be for a variety of reasons, despite the pregnant women's living in different settings. Furthermore, the findings of this study agreed with those of 22 Sub Sahara African [21], Nigeria [22], West Iran [64], Nepal [65], and Urban Slum [23]. This could be because educated pregnant women understand the benefits of iron supplementation as well as the risks that occur in the absence of iron supplementation and are therefore more compliant with iron supplementation in pregnancy. Nevertheless, the current study claims to be a study carried out in India [67].
Pregnant women who had high wealth quintiles were 82% less likely to be compliant with iron supplementation as compared to pregnant women who had low wealth quintiles. The present study's results were agreed with those of a study conducted in Ethiopia [18]. The current study's findings are supported by studies conducted in the Northwest, Ethiopia [29], and Nepal [65]. This could probably be because pregnant women who were socio-economically empowered thought that iron supplement intake affected them or their fetuses. However, this study disagreed with a study carried out in 22 SSA countries [21]. The possible explanation might be that pregnant women who had high wealth quantiles received information from a media outlet and understood the benefit of iron.
Pregnant women who got free iron supplements from government hospitals or health centers were 3.77 times more likely to be compliant with iron supplementation as compared to those who bought iron supplements from a private pharmacy. This current study’s results agreed with those of a study conducted in Senegal [70]. This could be because of socioeconomic status.
Pregnant women who had not experienced discomfort related to iron supplement intake were 2.94 times more compliant with iron supplementation during pregnancy as compared to pregnant women who had experienced discomfort related to iron supplement intake. The present finding agreed with a study carried out in Nigeria [22]. The possible explanation might be that educated pregnant women understand the benefits of iron supplementation and the consequences of anemia during pregnancy.
Nevertheless, this current study result was argued with a study conducted in Bangladesh [71], Iran [72], and Thailand [73] which indicated that gastrointestinal side effects were not significantly associated with compliance. This discrepancy could be because of cultural beliefs.
Pregnant women who had comprehensive knowledge of anemia were 2.62 times more likely to be compliant with iron supplement intake as compared to pregnant women who didn't have comprehensive knowledge of anemia. The present study supported a study conducted in four regions of Ethiopia [18]. Likewise, the current study findings agreed with several studies carried out in Northwest Ethiopia [46], Aykal Town [28], North Wollo Zone [49], and Ethiopia [55, 56]. The probable reason could be the awareness and educational status of the respondents.
Pregnant women who got free iron supplements from government hospitals or health centers were 3.77 times more likely to be compliant with iron supplementation as compared to those who bought iron supplements from a private pharmacy. This current study’s results agreed with those of a study conducted in Senegal [70]. This could be because of socioeconomic status.
Pregnant women who had not experienced discomfort related to iron supplement intake were 2.94 times more compliant with iron supplementation during pregnancy as compared to pregnant women who had experienced discomfort related to iron supplement intake. The present finding agreed with a study carried out in Nigeria [22]. The possible explanation might be that educated pregnant women understand the benefits of iron supplementation and the consequences of anemia during pregnancy.
Nevertheless, this current study result was argued with a study conducted in Bangladesh [71], Iran [72], and Thailand [73] which indicated that gastrointestinal side effects were not significantly associated with compliance. This discrepancy could be because of cultural beliefs.
Pregnant women who had comprehensive knowledge of anemia were 2.62 times more likely to be compliant with iron supplement intake as compared to pregnant women who didn't have comprehensive knowledge of anemia. The present study supported a study conducted in 4 regions of Ethiopia [18]. Likewise, the current study agreed with several studies carried out in Northwest Ethiopia [46], Aykal town [28], North Wollo Zone [49], and Ethiopia [55, 56]. The probable reason could be because of the awareness and educational status of the respondents. The current study’s findings were also supported by studies in SSA [58], Northwest Tanzania [74], and Cambodia [32]. The possible explanation could be that knowledge helps a woman have a good perception of the advantage of taking an iron supplement.
Pregnant women who had good knowledge of iron supplementation were 3.30 times more likely to be compliant with iron supplements as compared to pregnant women who had poor knowledge of iron supplementation. This current study was agreed with several studies carried out in Burji District [45], West Dembia, Ethiopia [46], Aykal town [28], North Wollo zone [49], Debre Tabor [48], Debre Markos town [52], Ethiopia [55, 56]. Likewise, the current study supported studies conducted in SSA [58], Kenya [60], Nigeria [22], Muntinlupa, and the Philippines [75]. Pregnant women who had good knowledge of iron supplementation might be more likely to receive information about iron supplements and understand education messages delivered via different media outlets.
Pregnant women who had information about the importance of iron supplementation during pregnancy were 2.86 times more compliant with iron supplementation as compared to pregnant women who had not gotten information about the importance of iron supplementation during pregnancy. The current study agreed with the studies conducted in Akaki Kality [30], Hawassa [26], Debre Tabor [48], Aykal Town [28], North Wollo zone [49], meta-analyses in Ethiopia [54–56], a study of four regions of Ethiopia [18], and Adwa Town [53]. The possible explanation might be that pregnant women who received information about iron supplements have increased their knowledge, attitude, and behavior.
A study conducted in SSA [58], Uganda [20], North West Tanzania [74], and Iran [72] found that most women received information on anemia and iron supplementation from health workers rather than other information sources such as the media, but their knowledge was still low regardless of the training.
Strength and limitations
This study used a community-based cross-sectional study, and it was representative of the source population. On the other hand, recall bias might occur due to self-reporting because the gold standard (like biochemical and stool tests) had not been used and this might have underestimated or overestimated the utilization and compliance with iron supplementation during pregnancy. The findings of this study might not be representative of the country. Since this study used a cross-sectional study, it could not establish a cause-effect relationship.