Utilization and compliance with iron supplementation and predictors among pregnant women in Southeast Ethiopia: a community-based cross-sectional study

DOI: https://doi.org/10.21203/rs.3.rs-1587247/v1

Abstract

Background

Globally, anemia affects 1.62 billion people (25%) of which 56 million are pregnant women. However, evidence for utilization and compliance with iron supplementation and predictors during pregnancy, in low-income countries, including Ethiopia, was sparse and inconclusive. Therefore, this study aimed to assess utilization and compliance with iron supplementation and predictors among pregnant women in Robe Town, Southeast Ethiopia.

Methods

Community-based cross-sectional study was employed among randomly selected 445 pregnant women attending antenatal care at health facilities from May to July 2015. Systematic random sampling was used to select respondents. Data were collected using a pre-tested interviewer-administered, structured questionnaire. Bivariable and multivariable logistic regression analyses were used to identify predictors of compliance with iron supplementation. An odds ratio, along with a 95% confidence interval (CI) was used to estimate the strength of the association.

Results

In this study, 54%; 95% CI: (49.4, 58.4%), 45.2%; 95% CI: (40.9, 49.4%), 4.3%; 95% CI: (2.5, 6.3%), and 2.2%; 95% CI: (1.1, 3.6%) of women received iron supplements during their first, second, third, and fourth antenatal care visits, respectively. The level of compliance with iron supplementation was 92.4%; 95% CI: (89.9, 94.6%). Having a formal education (AOR = 4.45, 95% CI: 1.41, 13.99), high wealth quintile (AOR = 0.18, 95% CI: 0.05, 0.68), medium wealth quintile [(AOR = 0.33, 95% CI: (0.11, 0.98)], iron supplements for free (AOR = 3.77, 95% CI: 1.33, 10.69), not experiencing discomfort related to iron supplements intake (AOR = 2.94, 95% CI: 1.17, 7.39), having comprehensive knowledge about anemia (AOR = 2.62, 95% CI: 1.02, 6.70), being knowledgeable about iron supplements (AOR = 3.30, 95% CI: 1.12, 9.76), having information about importance of iron supplementation during pregnancy (AOR = 2.86; 95% CI: 1.04, 7.87), and ever being visited by urban health extension workers (AOR = 0.31; 95% CI: 0.12, 0.83) was significantly associated with compliance with iron supplementation during pregnancy.

Conclusion

The utilization of iron supplementation during pregnancy was low, with relatively high compliance with the supplements. Thus, comprehensive nutrition education and free provision of iron supplementation are crucial tools to increase utilization and compliance with iron supplementation during pregnancy. Further research with a strong study design using golden standard methods is warranted.

Introduction

Anemia is one of the most prevalent nutritional disorders worldwide, affecting populations in both high-income countries (HICs) and less developed countries. The global prevalence of anemia was estimated to be 38% (32 million) in pregnant women. However, the prevalence of anemia is increasing in low and middle-income countries (LMICs) with a rate of 50.1–76.7% [13]. Africa has the highest prevalence of anemia, with 57% of pregnant women [4]. Several studies carried out in Ethiopia also revealed that the prevalence of anemia among pregnant women ranges from 21 to 54% [59]. Maternal anemia is associated with mortality and morbidity for the mother and baby, including the risk of miscarriages, stillbirths, prematurity, and low birth weight. It impairs children’s development and learning too, further impacting economic productivity and development [10].

By 2025, the World Health Organization (WHO) aims to reduce anemia in women of reproductive age by half [10]. In Ethiopia, nutrition is integrated into the health sector transformation plan in the form of micronutrient interventions to prevent the occurrence of anemia and improve the nutritional condition of mothers during pregnancy [11]. Maternal and child mortality remain high in Ethiopia, with 412 maternal deaths per 100,000 live births and 67 child deaths per 103 live births reported [12]. Taking this into account, the Ethiopian government has demonstrated its commitment to averting nutritional problems by adopting food and nutrition policies, strategies, and programs. In addition, the government designed the Seqota declaration to eliminate stunting by 2030 [13]. Various factors, such as socio-demographic and health factors, determine the compliance with iron supplementation among pregnant women [14]. All pregnant women in places where anemia is common should take iron supplements, according to the WHO [15]. Despite the WHO's recommendation, iron supplementation is nevertheless uncommon in many countries, particularly in those with limited resources [16].

The national guideline for the control and prevention of micronutrient deficiencies emphasized the necessity of daily iron supplementation for at least 6 months during pregnancy and 3 months after delivery, in line with WHO recommendations [17]. By 2015, the national nutrition strategy (NNS) aims to increase to 50% the proportion of women who receive iron supplements for more than 90 days during pregnancy and the postpartum period [18].

In the previous five years, only 17.3 percent of women used iron supplements during their most recent pregnancy, and only 0.4 percent supplemented for 90 days or more. Even though iron supplementation is thought to be an important aspect of prenatal care (ANC), only 37% of women who had ANC received it [12]. Low adherence has an impact on the level of energy and productivity, cognitive and physical development, and immune function [19]. Several studies reported that the compliance rate of iron supplements during pregnancy was low. For example, the compliance rates vary from 12–93% [20–24].

Previous studies have employed a cut-off point of  90 days to determine adherence to iron supplementation during pregnancy in sub-Saharan Africa (SSA) [18, 25–28]. However, many women in SSA countries do not take iron supplements because of socio demographic-economic factors [20, 25, 29–31], lack of knowledge about anemia, inadequate supply of iron tablets, poor utilization of ANC services, inability to pay for supplementation, misinformation about the benefit of supplementation, complaints about side effects, forgetfulness, and poor counseling [18, 25, 32, 33].

Although prenatal iron supplementation was an integral part of antenatal care and was provided free of charge in Ethiopia, the existing compliance rate of iron supplements varies from 28.1 to 87.6% [34, 35]. Nevertheless, evidence on utilization and compliance with iron supplementation and predictors among pregnant women in low-income countries like Ethiopia, in general, and in the study context, in particular, is sparse and inconclusive. The findings of this study could be used by policymakers to improve utilization and compliance with iron supplementation during pregnancy. Therefore, we aimed to assess the utilization and compliance with iron supplementation and predictors among pregnant women at Robe town, Bale zone, Southeast Ethiopia.

Methods

Study design, setting, and participants

A community-based cross-sectional study design was used among pregnant women attending antenatal care at health facilities in Robe Town, Bale zone, Southeast Ethiopia from May to July 2015. The majority of the inhabitants were Muslim (48%), Orthodox (45%), and Protestant (6%). There was one government district hospital. Besides, there were 15 private clinics, 12 drug vendors, and one health center. Five of the 12 drug vendors served rural areas. All health facilities provide antenatal care (ANC) visits. There were also primary and secondary schools, a teachers' training college, and Madda Walabu University in the town. The Robe was entirely engulfed by peasant associations. The child-bearing age women counted were 13,685. The estimated number of pregnant women was 2,146 [36, 37].

All pregnant women who attended the ANC clinic were the source population. All randomly selected pregnant women attending the ANC clinic who fulfilled the inclusion criteria and who received the iron supplement for at least one month before the date of interview were included in the study.

Sample size determination and sampling techniques

The sample size was calculated using the G-power software version 3.1, assuming an effect size of 0.25, a 95% confidence interval, a precision of 0.05, and a power (1- β) of 80% [38]. The computed sample size was 206. Using a design effect of 2 and adding a 10% non-response rate, the final sample size was 454.

The three kebeles (the smallest administrative unit in Ethiopia) were selected at random and their respective numbers of pregnant women were obtained from the study town health office. Then, the sample size was proportionally allocated to each kebele and the pregnant women were selected using a systematic random sampling technique. If a woman was absent from her house during the interview, an eligible pregnant woman in the next house in serial number was interviewed. The house of absent pregnant women was revisited the next day.

Data collection

An interviewer-administered, structured questionnaire was used to collect data, which was first developed in English and then translated into the local language, Afan Oromo. The questionnaire was comprised of questions related to socio-demographic and economic factors such as age, marital status, religion, ethnic group, head of household, occupation of the women and husband, educational status of women and husband, wealth index, and family size.

Iron supplements and health-related factors included the experience of discomfort related to iron supplement intake encountered, a dose of iron supplement, knowledge of anemia's causes, symptoms, and prevention, knowledge of iron supplements, beliefs towards iron supplement intake may harm the fetus, ever forgotten iron supplement intake, knowledge of anemia, information about iron supplementation, and source of information.

Questions related to health care delivery system-related factors were: a source of iron supplement, distance from the nearest health facility, urban health extension worker visit, and ANC services. Obstetric-related factors were also birth order, intended pregnancy, gestational age, the experience of serious pregnancy-related complications, and parity.

To assure the quality of the data, the questionnaire was initially developed in English and then translated into the local language "Afan Oromo" and back-translated into English by independent language experts to assure its consistency. The questionnaire was also pretested on 5% of the total estimated sample size, having similar characteristics to the study population in a different setting. Necessary modifications were made to the questionnaire for the actual task of data collection. The training was given to data collectors, level IV nurses, and supervisors on the objectives of the study, data collection instruments, and principles of research ethics to minimize interviewers' bias. Data supervisors closely supervised the data collectors daily for the successful completion of the questionnaire and timely action otherwise. The study participants were interviewed at their homes to improve the response rate.

Operational definitions

Utilization of iron supplementation and compliance with iron supplements during pregnancy were outcome variables. In this study, the utilization of iron supplementation during pregnancy was the proportion of a pregnant woman who has been supplemented previously for at least one month before the date of the interview. It was measured by how many pregnant women have used iron supplements. Compliance with/adherence to iron supplements during pregnancy was understood in such a way that a pregnant woman was said to be compliant/adherent to iron supplements if she took the supplement for at least 4 days a week during pregnancy in the previous one month preceding the survey otherwise they were classified as non-compliant/adherent to iron supplement. Self-report compliance/adherence was estimated by asking a woman how many times she took a supplement per week in the previous time [4, 39].

Comprehensive knowledge of anemia during pregnancy was measured in this study in which respondents who were aware of anemia and know at least one of its major causes, symptoms, and consequences during pregnancy were said to be knowledgeable about anemia. On the contrary, knowledge of iron supplementation was measured based on a set of four questions including (1) awareness of iron supplementation in pregnancy, (2) reasons for iron supplementation, (3) possible side effects of oral iron preparation on women, and (4) possible effects of iron deficiency. Respondents who answered correctly 3 or 4 of the above questions were considered to have good knowledge of anemia during pregnancy whereas those who answered correctly to two or fewer were said to have poor knowledge [22].

Knowledge of iron supplementation during pregnancy was based on the participants' responses to a set of four questions including (1) awareness of iron supplementation in pregnancy, (2) reasons for iron supplementation, (3) possible side effects of oral iron preparation on the women, and (4) possible effects of iron deficiency on pregnancy. Respondents who answered correctly to 3 or 4 of the above questions were considered to have good knowledge of iron supplementation in pregnancy whereas those who answered correctly to two or fewer were said to have poor knowledge [22].

The economic status of respondents was ranked ordered into tertiles as rich, medium, and poor using the wealth index. The wealth index was assessed by computing principal component analysis using household asset items and other variables [12].

Statistical analysis

Data were checked for completeness, consistency, and accuracy. Then, the data were entered, cleaned, and analyzed using SPSS version 20 computer software. Descriptive statistics such as frequencies, percentages, and mean were computed for selected explanatory variables. Bivariable logistic regression analysis was conducted to see the association between each predictor and compliance with iron supplement (Yes = 1, No = 0). Variables with a p-value of ≤ 0.25 were included in multivariable logistic regression analyses to control for all possible confounder effects. Multicollinearity was tested among all independent variables using a correlation matrix (R). The highest correlation between the independent variables was 0.16, which was below the cut-off points. Adjusted odds ratio (AOR) along with a 95% confidence interval (CI) was estimated to identify predictors of the outcome variable. The goodness of fit of the final logistic model was tested using Hosmer and Lemeshow's test at a p-value of > 0.05. All statistical tests in this study were considered two-tailed and declared significant at a p-value < 0.05.

Results

Socio-demographic and economic characteristics

A total of 445 out of 454 pregnant women, were included in the study, yielding a response rate of 98%. Nearly half 214 (48%) of pregnant women were less than or equal to 24 years of age, with a mean (± SD) age of 25 (± 5.42) years. Almost all (98%) of the pregnant women were married, and half of them were Muslims. The majority of the respondents (82.5%) were from the Oromo ethnic group. Half of the households were headed by husbands. More than half (58.4%) of the respondents were housewives, whereas (2.7%) were farmers. The majority of the respondents (94.6%) were literate, and about (30.8%) of the households had high wealth quintiles (Table 1).

Table 1: Socio-economic and demographic characteristics of pregnant women attending antenatal care at Robe Town, Bale zone, Southeast Ethiopia, 2015 (n = 445). 

 
Table 1

Socio-economic and demographic characteristics of pregnant women attending antenatal care at Robe Town, Bale zone, Southeast Ethiopia, 2015 (n = 445).

Variables

Frequency

Percent

Age (years)

24

214

48.1

25–34

187

42.0

 35

44

9.9

Marital status

Married

437

98.2

Others (widowed, divorced, separated & never married)

8

1.8

Religion

Orthodox

185

41.6

Muslim

223

50.1

Other (Protestant)

37

8.3

Ethnic group

Oromo

367

82.5

Amhara

67

15.1

Others (Gurage, Silte and Hadiya)

11

2.5

Head of household

Husband

223

50.1

Wife

15

3.4

Both

207

46.5

Maternal occupation

Wife

260

58.4

Farmer

12

2.7

Daily labor

23

5.2

Government employee

83

18.7

Private employee

54

12.1

Petty trade

13

2.9

Variables

Frequency

Percent

Paternal occupation

Farmer

58

13

Government/private employee

148

33.3

Petty trade

93

20.9

Other

146

32.8

Maternal education

Illiterate

35

7.9

Some education

410

92.1

Paternal education

Illiterate

24

5.4

Literate

421

94.6

Household wealth index

High

137

30.8

Medium

201

45.2

Low

107

24

Family size

1–3

275

61.8

4–6

144

32.4

 7

26

5.8


Utilization of iron supplements during pregnancy

Out of 445 pregnant women who were enrolled in the study, 54%; 95% CI: (49.4, 58.4%), 45.2%; 95% CI: (40.9, 49.4%), 4.3%; 95% CI: (2.5, 6.3%), and 2.2%; 95% CI: (1.1, 3.6%) of women received iron supplements during their first, second, third, and fourth antenatal care visits, respectively. Of 445 pregnant women who were given iron supplements, 46.7%; 95% CI: (42.2, 51.5%), 33.9%; 95% CI: (29, 37.8%), 18.2%; 95% CI: (14.4, 22.2%), and 1.1%; 95% CI : (0.2, 2.2%) of them received iron supplements for 30 days, 31–60 days, 61–90 days, and more than 90 days, respectively (Fig. 1).

Figure 1: Utilization of iron supplementation among pregnant women at Robe town, Bale zone, Southeast Ethiopia, 2015 (n = 445)

Compliance with iron supplements during pregnancy

The rate of compliance with iron supplementation during pregnancy was found to be 92.4%; 95% CI: (89.9, 94.6%).

Predictors of compliance with iron supplements during pregnancy

In bivariable logistic regression analysis, being literate, free of charge iron supplement, not experiencing discomfort related to iron supplement intake, satisfied with the dose and form of iron supplement, having comprehensive knowledge of anemia, not interrupting iron supplement intake, having good knowledge of iron supplement and having information about the importance of iron supplementation during pregnancy was significantly associated with compliance with iron supplements during pregnancy (P-value < 0.05). Nevertheless, in multivariable logistic regression analysis, women’s literacy (AOR = 4.45, 95% CI: 1.41, 13.99), the medium (AOR = 0.33, 95% CI: 0.11, 0.98), and high (AOR = 0.18, 95% CI: 0.04, 0.68) wealth quintiles, absence of discomfort or adverse effects related to iron supplements (AOR = 2.94, 95% CI: 1.17, 7.39), women’s having comprehensive knowledge of anemia (AOR = 2.62, 95% CI: 1.02, 6.70) and having good knowledge of iron supplements (AOR = 3.30, 95% CI: 1.12, 9.76), having information about the importance of iron supplementation (AOR = 2.86, 95% CI: 1.04, 7.87), being visited by urban health extension workers (AOR = 0.31, 95% CI: 0.12, 0.83) were found to be significant predictors of compliance with iron supplements during pregnancy (Table 2). 

 
Table 2

Predictors of compliance with iron supplementation among pregnant women at Robe town, Bale Zone, Southeast Ethiopia, 2015 (n = 445).

Variables

Compliance with iron supplementation

Yes No

n (%)

n (%)

COR

95% CI

AOR

95%CI

Respondent education

Illiterate

27 (77.1)

8 (22.9)

1

 

1

 

literate

384 (93.7)

26 (6.3)

0.23

0.09 to 0.56

4.45

1.41 to 13.99*

Wealth index

High

130 (94.9)

7 (5.1)

0.67

0.23 to 1.90

0.18

0.05 to 0.68*

Medium

182 (90.5)

19 (9.5)

0.52

0.21 to 1.26

0.33

0.11 to 0.98*

Low

99 (92.5)

8 (7.5)

1

 

1

 

Experienced discomfort related to iron supplement

Yes

146 (86.9)

22 (13.1)

1

 

1

 

No

265 (95.7)

12 (4.3)

3.33

1.60 to 6.92

2.94

1.17 to 7.39*

Satisfied with dose

Yes

346 (94.5)

20 (5.5)

3.73

1.79 to 7.75

1.99

0.76 to 5.23

No

65 (82.3)

14 (17.7)

1

 

1

 

Comprehensive knowledge of anemia

Yes

317 (95.8)

14 (4.2)

4.82

2.34 to 9.91

2.62

1.02 to 6.70*

No

94 (82.5)

20 ( 17.5)

1

 

1

 

Forgotten iron supplement intake in between

Yes

143 (89.9)

16 (10.1)

1

 

1

 

No

268 (93.7)

18 (6.3)

1.67

0.82 to 3.37

0.94

0.38 to 2.36

Thought too many iron supplement intake may harm the fetus

Yes

73 (88)

10 (12)

1

 

1

 

No

338 (93.4)

24 (6.6)

0.52

0.24 to 1.13

1.56

0.61 to 3.97

Ever interrupted iron supplement intake

Yes

121 (87.7)

17 (12.3)

1

 

1

 

No

290 (94.5)

17 (5.5)

2.40

1.18 to 4.85

1.84

0.69 to 4.90

Knowledge of iron supplementation

≤ 2

162 (85.7)

27 (14.3)

1

 

1

 

≥ 3

249 (97.3)

7 (2.7)

5.93

2.53 to 13.93

3.30

1.12 to 9.76*

Information about the importance of iron supplementation

Yes

335 (94.9)

18 (5.1)

3.92

1.91 to 8.03

2.86

1.04 to 7.87*

No

76 (82.6)

16 (17.4)

1

 

1

 

Source of iron supplement

Private pharmacy

47 (82.5)

10 (17.5)

1

 

1

 

Free hospital/H/C

364 (93.8)

24 (6.2)

3.23

1.45 to 7.17

3.77

1.33 to 10.69*

Ever been visited by UHEW

Yes

132 (89.2)

16 (10.8)

0.53

0.26 to 1.08

0.31

0.12 to 0.83*

No

279 (93.9)

18 (6.1)

1

 

1

 

Experienced serious pregnancy complications

Yes

59 (86.8)

9 (13.2)

1

 

1

 

No

352 (93.4)

25 (6.6)

2.95

0.96 to 4.83

0.65

0.22 to1.94

Gestational age

≤ 12

3 (75)

1 (25)

1

 

1

 

13–24

92 (92)

8 (8)

3.83

0.36 to 41.24

0.89

0.04 to 20.48

≥ 25

316 (92.7)

25 (7.3)

4.20

0.42 to 42.00

1.11

0.06 to 22.60

* Statistical significant (P-value < 0.05); CI: Confidence interval; COR: Crude odds ratio; AOR: Adjusted odds ratio; 1: Reference category; UHCW: Urban healthcare worker


Discussion

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.

Conclusion

This study demonstrated that the utilisation of iron supplementation during pregnancy was low, with a high level of compliance with the supplements. It was also revealed that the most common types of discomfort experienced by pregnant women who took iron supplements were gastric burning and headaches. The study also identified that being literate women, being free of charge iron supplements, not experiencing discomfort related to iron supplement intake, having comprehensive knowledge of anemia, having good knowledge of iron supplementation, and information about the importance of iron supplementation during pregnancy were factors significantly affecting compliance with iron supplementation during pregnancy. However, high wealth quintiles, medium wealth quintiles, and ever being visited by urban health extension workers were less likely to be associated with compliance with iron supplementation during pregnancy. The proper delivery of training to pregnant women on anemia causes, symptoms, consequences, and prevention, as well as the benefits of iron supplementation, is crucial. There should be a continuous and timely provision of iron supplements for health facilities. Enhance access to the utilisation of iron supplementation for pregnant women and create awareness of the early start of iron supplementation. The findings of this study have implications for clinicians and policymakers. Further research with a strong study design using golden standard methods is warranted.

Abbreviations

ANC, Antenatal Care; CSA, Central Statistical Agency; EDHS, Ethiopia Demographic and Health Survey; FMOH; Federal Ministry of Health; LBW, Low Birth Weight; NNS, National Nutrition Strategy; SPSS; Statistical Package for Social Science; SSA; Sub Saharan Africa; SDGs; Sustainable Development Goals; UHEW; Urban Health Extension Worker; WHO;  World Health Organization

Declarations

Acknowledgments

Our heartfelt appreciation and thanks extend to supervisors, data collectors, respondents, and individuals who enormously engaged in the study.

Authors’ contributions

GB: Participated in the conception, design, data analysis, and writing up of the manuscript. BL: Participated in the conception, design, and finalizing of the manuscript. TB: Participated in the conception, design, data analysis, and finalizing of the manuscript. GE: Participated in the conception, design, data analysis, and finalizing of the manuscript. All authors read and approved the manuscript.

Competing interests: None.

Ethical considerations

The current study was ethically cleared by the Institutional Review Board of Hawassa University before the starting of the study (Protocol Number: IRB/07/07). A permission letter was obtained from Bale Zone and Robe Woreda/district health offices. Informed written consent was secured from each respondent. The privacy of the respondents was maintained. Confidentiality was assured throughout the process of the entire data collection and management.

Funding: We didn’t receive a specific fund for this study.

Conflicts of interest: None

Patient consent for publication: Not applicable

Data availability statement: Data are available upon reasonable request

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