Determinants of non-adherence to Iron Folic Acid Supplementation among Pregnant Women Attending Public Health Facilities in Bishoftu Town, Ethiopia: Case-Control study

doi:10.21203/rs.3.rs-3250049/v1

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Determinants of non-adherence to Iron Folic Acid Supplementation among Pregnant Women Attending Public Health Facilities in Bishoftu Town, Ethiopia: Case-Control study

https://doi.org/10.21203/rs.3.rs-3250049/v1

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Background: Iron folic acid supplementation is one of the most global public health interventions to alleviate iron deficiency anemia during pregnancy. Both folic acid and iron deficiencies constitute the major micronutrient deficiencies in Ethiopian women.Non-adherence, on the other hand, is a factor in these communities' failure to reduce the problem.

Objective: To identify determinants of non-adherence to iron-folic acid intake among pregnant women who attended antenatal care in Bishoftu town public health facilities, Ethiopia 2022.

Methods: Facility-based unmatched case-control study was conducted from April 1 to May 30, 2022. A total of 105 cases and 211 controls of pregnant women participated in the studyby structured questionnaire and using systematic random sampling methods for control and consecutive sampling was used for the case. Characteristics of the study participants were analyzed using descriptive Statistics. Variable with P-value < 0.25 at the bivariable analysis was entered into the final multivariable logistic regressions to control potential confounders. Model fitness was also checked by Hosmer Lemeshow. An adjusted odds ratio with a 95% confidence interval and a p-value of ≤0.05 was used to declare the statistical significance of variables.

Results: The study response rate was 314 (99.4%). The identified determinants were women aged 15-24 years and 25-34 years [AOR=5, 95% CI (3.04, 12.8), AOR=11.8, 95% CI (18, 20.6)], women who started first ANC >16 weeks (AOR=2.41, 95% CI:1.107, 5.252), women who receive ANC visit two and three were [AOR=5.17, 95% CI (2.5, 13), AOR=2.95 95% CI (1.26, 6.8)], women with inadequate knowledge (AOR=3.5,95% CI:1.7,7.2), women who received 30 and below tablets (AOR=7.8, 95% CI:4, 18) were determinants of non-adherence to iron-folic acid supplementation

Conclusions: Women's age, pregnancy weeks during first ANC, frequency of ANC follow-up, knowledge of women on iron-folic acid supplementation, women who received 30 and below tabletswere significant predictors for non-adherence to folic acid supplementation.Thus, the town health office should work on non-adherence to folic acid supplementation by improving knowledge of women for all age groups of women during ANC visits with concerned stakeholders.

Pregnant women

Iron Folic acid

Iron supplementation

Non-adherence to folic acid

Bishoftu town

Non-adherence to iron-folic acid medications can occur in the situations or combinations thereof: late or non-initiation of the prescribed treatment, sub-optima implementation of the dosing regimen, or early discontinuation of the treatment (1). Iron deficiency is the most common nutritional disorder in the world and pregnant women are especially at risk (2).

Globally iron deficiency alone accounts for 22% of all anemia deaths. In sub-Saharan Africa, anemia contributed to approximately 28.6% of maternal deaths (4). The most common causes of anemia are poor nutrition, deficiencies of iron, micronutrient deficiencies including folic acid, vitamin A, and vitamin B12 (9). It is estimated to affect 38.2% of pregnant women globally, with the highest prevalence in the WHO regions of South-East Asia at 48.7% and Africa 46.3% (10).

Women of reproductive age are at particular risk because of menstruation, whereas pregnancy and childbirth result in a net iron loss of 580 to 680 mg because of fetal and placental requirements and bleeding during delivery, in young children, rapid expansion in red cell mass results in very high dietary iron requirements (3). It is also responsible for some pregnancy complications, such as neural tube defects, including spinal bifida and anencephaly, fetal malformation, type 2 diabetes, and obesity in the newborn (4, 5).

In Sub-Saharan Africa, the overall prevalence of ≥ 90 days of iron supplementation adherence during pregnancy was only 28.7%. Likewise, there is very low adherence to Iron Folic Acid supplementation among pregnant women, which is 11% in Ethiopia (11). One in every three women had anemia while one in every two had iron and folic acid deficiency, indicating that both folic acid and iron deficiencies constitute the major micronutrient deficiencies in Ethiopian women (8). Iron and folic acid are required for appropriate physiological function, growth, and development, as well as life maintenance. Their demand, like that of many other nutrients, rises during pregnancy, necessitating supplementation to meet daily requirements (6).

In Ethiopia, the coverage of iron supplementation during pregnancy is still low and has not fulfilled the World Health Organization (WHO) standard recommendations (12, 13). Iron folic acid intake among pregnant women is a core process indicator of the global nutrition monitoring framework that helps to halt the burden of iron deficiency anemia worldwide, especially in low-income countries including Ethiopia (7). According to the WHO and Ethiopia’s national guidelines for the control and prevention of micronutrient deficiencies, all pregnant women should receive and consume a standard dose of 60mg iron and 400 mg folic acid daily for 6 months starting from the first month of pregnancy or at the time of their first antenatal visit and three months of postnatal period (8)

Previous studies showed that pregnant women were not fully adhered to their iron folate supplement because of many factors; among factors non-adherent to iron/folate supplementation age, didn’t get nutrition counseling, and women lacking knowledge of anemia were associated with a higher likely hood of non-adherence with IFAS (14). Similarly, factors contributing to iron and folic acid non-adherence were forgetfulness, taking too many pills, not knowing the usefulness of iron and folic acid supplementation, fear of the side effects of the medication including nausea, vomiting, and unpleasant tests of the supplement (15, 16).

Also, misinformation includes; fear to give birth to a big baby, spot-on teeth of children and face of mothers, difficult delivery, not beneficial to babies, mothers experience with no history of having children with neural tube defects, and more bleeding during delivery was associated with low adherence to IFAS (17, 18). Medication non-adherence leads to poor outcomes, which then increase healthcare service utilization and overall healthcare costs (19). Women who failed to consume the iron tablets would experience iron folic acid (IFA) deficiency anemia and associated negative effects on mothers and newborns (4). This indicates the identification of determinants of non-adherence to iron-folic acid supplementation among pregnant women.

Moreover, the identification of determinants of non-adherence to iron-folic acid supplementation among pregnant could be used to take intervention and alleviate the risk of maternal anemia and fetal complication. There is limited evidence on determinants of non-adherence to Iron Folic Acid supplementation and most of the previous studies conducted in Ethiopia were focused on adherence to Iron Folic Acid supplementation and associated factors with cross-sectional study design which can determine exposure and disease at the same time. Therefore, the purpose of this study is to fill this gap and aimed to identify the determinants of non-adherence to iron-folic acid supplementation among pregnant women attending public health facilities in Bishoftu Town, Ethiopia.

2.1 Study Design, Period, and Area:

The facility-based unmatched case-control study design was conducted in Bishoftu Town, Ethiopia from April 1 to May 30, 2022. Bishoftu Town has 1 public general hospital that provides health services for three sub-city and five districts with greater than 1.2 million people. Furthermore; the town has 5 public health centers under the Bishoftu Town Health Bureau and each health center provide service for a total of 40, 000 population. All health facility provides maternal and child health service and also other services. A total of 385 health professionals & 193 supportive staff of governmental employers provide health services to the community. As yearly national growth rate reported the total population of the town was estimated to be in 2022 is about 234,970 and the expected number of pregnant was 8153. Bishoftu town has 1 private hospital, 1 privet health center, and 103 all types of private clinics in the town. All the fourteen health posts found in the town started implementing the urban health extension program and providing primary health care services for the town population and nearby communities.

2.2 Source and study population:

The source population was all pregnant women who attend Antenatal care in public health facilities in Bishoftu Town and the study population was all selected pregnant women who started ANC service in the public health facilities in Bishoftu Town during data collection.

Cases

Pregnant women who started ANC service and take iron/folate supplements one month before data collection on the selected health facility and who take IFA tablets less than 4 days per week were considered as cases (15, 23, 37). Controls: Pregnant women who started ANC service and take iron/folate supplements one month before data collection on the selected health facility and who take IFA tablets greater or equal to 4 days per week were considered as controls (15, 23, 37)

2.3 Eligibility criteria

Inclusion criteria

Pregnant women who started ANC service and take iron/folate supplements one month before data collection from the selected health facilities.

Exclusion criteria: Mothers who are critically ill or in emergency condition at the time of data collection and who don’t prescribe the IFAS.

2.4 Sample size determination

The sample size was calculated based on the double population proportion formula by using Epi Info statistical software version 7.2.2 for unmatched-case–control study design by considering the determinant variables from previous case-control studies conducted in Ethiopia (27) and compared to get a large sample (13). The predictor variable registration time was considered a significant determinant of the non-adherence to iron-folic acid supplementation from previous studies since it gave the maximum sample size. Among controls, 52% of mothers has not attended postnatal care follow-up, while among cases it was 34% and OR = 2.10 (13). Using the assumptions of 80% power (Zβ = 0.84), 95% confidence level (Zα/2 = 1.96), a case-to-control ratio of 1:2, and after adding a 10% non-response rate, the total sample size was 316 (105 cases and 211 controls).

2.5 Sampling procedure

In this study, public health facilities found in the Town were included in the study purposefully. The number of study participants was assigned to each health facility proportional to the client size attended per year (Fig. 1). These health facilities are chosen for recruiting cases and controls since they are providing ANC services. Finally, consecutive sampling was used for case selection, and systematic random sampling methods were used for control selection by using the registration log of clients currently who start ANC follow-up and who took at least IFA for one month before data collection and k^th=6. Registration was used as a sampling frame for controls

2.6 Data collection tool and procedures

The data collection was carried out by using structured questionnaires filled by data collectors. The majority of questionnaires were adapted, modified, and developed by reviewing different literature (14, 23, 37). The questionnaire is prepared in English and translated to the local language Afan Oromo by a language professional to better understand both data collectors and respondents and translated back to the English version to check consistency. The questionnaires include the participant's socio-demographic characteristics, wealth index of household, obstetric and health-related characteristics, health-care-related variables, client-related factors (knowledge), and other topics. During recruitment, relevant information about the study was imparted to clients. ANC Registration log was used for the sampling frame.

Data were collected using interviewer-administered structured questionnaires and interviewer-administered questionnaires. In addition to this, relevant information was retrieved from the records. The interview was conducted face to face with clients about how many IFAS tablets have taken per week. Cases and controls were declared by the first data collectors as cases if the client took IFAS less than 4 tablets and controls if clients took IFAS at least 4 and above tablets per week and the questionnaire was filled by the second data collector based on the training given by the investigator.

Ten diploma midwives were recruited to conduct an interview who was fluent in the local language with one Health officer supervisor. The data collector and supervisor were trained on how to fill in the information on a structured questionnaire and the objective of the study. The supervisor checked for the completeness and consistency of data collected by the data collector. To collect qualified data the ethical aspect of approaching the patients, and keeping the confidentiality of their knowledge was another focus of the training. Data collectors were given personal protection equipment. The data-gathering method was overseen by the investigator.

2.7 Study variable

2.7.1 Dependent Variable

Non-Adherence to Iron Folic Acid supplementation

2.7.2 Independent Variables

Socio-demographic factors such as maternal age, maternal occupation mothers/husband, residence, educational status of mother/husband, marital status, religion, wealth index

Obstetric factors such as parity, gravidity, number of ANC visits, ANC initiation time, history of abortion, Stillbirth, History of chronic disease, knowledge of women on the iron foliate supplement, the iron foliate drug, the benefit of iron foliate supplement, health facility-related factors, distance from the health facility, get medical advice, encounter shortage of supplement

2.8 Operational definition

Non-Adherence When a pregnant woman visiting an antenatal clinic took IFAS tablets for less than four days per week during the 1 month preceding the study (14, 38).

Adherence

According to the WHO definition of Adherence to IFA supplementation, Women are considered to have adhered to an iron/folic acid supplement if they took 65% or more of the supplement, equivalent to taking the supplement at least 4 days a week (16, 18, 32). In these study also when a pregnant woman visiting an antenatal clinic took IFAS tablets for greater than four days per week during the 1 month preceding the study.

IFA Supplement

Provision of a specified dose of nutrient preparation containing iron and folic acid compound that is prescribed to pregnant women for either treating an identified deficiency or prevention of the occurrence of such a deficiency in an individual(13, 39).

Wealth Index

There are several ways in which wealth, economic status of households, and living standards can be measured. Income, expenditure, and consumption are three common measurements(40, 41).

Good knowledge of IFA

Pregnant women were said to have good knowledge of IFAS if they score greater than the mean score for the knowledge question (8, 11).

Trimester: The number of weeks during pregnancy (1st, 1–12 weeks, 2nd, 13–26 weeks, 3rd, 27–40 weeks)(39). Preconception folic acid supplementation: standard recommendation of folic acid (400µg/day) for all women from the moment they begin trying to conceive until 12 weeks of gestation should take folic acid supplements (10).

2.9 Data quality assurance

The questionnaires, which were prepared in English version, were translated into the local language Afan Oromo, again back to English by an experienced language professional to ensure their validity and consistency. A pretest of the data collection tool was carried out on 5% of the sample size at Dukem health center out of a selected public health facility which was a similar setup to the study area before the actual data collection. The training was given to data collectors and supervisors on the research objectives, eligible study subjects, data collection tools and procedures, and interview methods.

On each data collection, the name of the data collectors was recorded to enhance the responsibility for any incomplete data; and collected data were examined by supervisors through daily follow-up of data collectors with checklist and incompleteness and missed variables checked during supervision. The principal investigator also supervises overall data collection, resource scarcity, and any forwarded problem was got immediate solution.

2.10 Data processing and analysis

The collected data were checked for completeness, accuracy, clarity, and consistency. The collected data were entered into a computer using Epi-data 4.6.2 and exported to SPSS version 25 for processing and analysis. Before analysis, data processing activities such as recording, computing, ranking, and counting were performed. Then first the characteristics of study participants were explored using descriptive statistics such as frequency distribution and summary statistics. To identify independent variables that have a crude association with non-Adherence to IFA, Binary logistic regression was used. All variables with a P value < 0.25 were considered as candidates for multivariable logistic regression to control for possible confounding effects. Multivariable logistic regression was applied to see the independent effect of each variable on the outcome variable. Collinearity between and among variables was assessed by variance inflation factor (VIF) i.e. 1.0, and model fitness was also checked by Hosmer Lemeshow greater than 0.05, Omnibus test significance value of less than 0.05 indicates that the current model fit. The final results of the association are presented based on AOR at 95% CI and p < 0.05 were considered statistically significant. Finally, the result of the study was presented in text, graph, figure, and table forms.

3.1 Socio-demographic characteristics of respondents

A total of 314 (105 cases and 209 controls) participants were included in the study, which gives a response rate of 99.4%, and 2 participants were excluded due to the incompleteness of the data. Their mean age was 26.8 (SD ± 5.2) years, and 102 (48.8%) controls of them were 35years and 57(54%) cases of them were 25-34years. The majority of the study participants in the control group 169(80%) and 91(87%) of the cases participants were urban residents, 191 (91%) of the controls, and 96 (9%) of cases were married. Regarding educational status,66 (31.5%)controls and 33 (31%) of cases % of the respondents attended secondary education, 109(52%)controls and 54(51%) cases were Oromo in ethnic, 84(40.2%)of controls and 41(39% )of cases of participants were orthodox,63( 30%)of controls and26 ( 24.7%) of cases were housewife and about 86 (41% )controls and 54 ( 51% ) of cases were higher wealth status (Table 1).

Table 1

Socio-demographic characteristics of respondents among pregnant women attending ANC in public health facility Bishoftu Town, Oromia, 2022.
Variables	Controls		Cases
Variables	Frequency	%	Frequency	%
Age of participants
15–24 Age	67	32.1%	39	37%
25–34 Age	40	19.1%	57	54%
≥ 35 Age	102	48.8%	9	9%
Religions
Orthodox	84	40.2%	41	39%
Muslim	45	22%	24	23%
Protestant	67	32%	36	34%
Other specify*	13	6%	4	4%
Residence
Rural	40	19%	14	13%
Urban	169	81%	91	87%
Marital status
Married/live together	191	91%	96	9%
Single	10	5%	5	5%
Divorced/separated	7	3%	4	4%
Widowed	1	0.5%	0
Ethnicity
Oromo	109	52%	54	51%
Amara	56	27%	26	25%
Tigray	15	7%	8	8%
Gurage	25	12%	13	12%
Other specify **	4	2%	4	4%
Mothers Education
Can’t read and write	37	18%	5	5%
Read and write	9	4%	17	16%
Primary (1–8)	45	21.5%	26	25%
Secondary(9–12)	66	31.5%	33	31%
Diploma and above	52	25%	24	23%
Mothers occupation
Government employee	35	17%	22	21%
Non-governmental employee	52	25%	25	24%
Daily laborer	13	6%	7	6.6%
Student	43	21%	22	21%
Housewife	63	30%	26	24.7%
Other(specify)***	3	1%	3	2.8%
Wealth index category
Lower wealth status	72	34%	35	33%
Medium wealth status	51	24%	16	15%
Higher wealth status	86	41%	54	51%
wakefata &catholic, Tigray & Wolaita, **farmer, merchant & driver

3.2 Obstetric History of pregnant women

Regarding their obstetric history of respondents, 314 women who have 2–4 pregnancies were 121(58%) controls and 58 (55%) cases, 71(53%) of controls and 29 (50%) cases had experienced 2–4 deliveries. From the study 175(84%) controls & 86 (82%) cases respondents have not faced abortion in the past pregnancy. All of the women in this study received ANC service. From these 165(79%) controls and 66(63%) cases of participants start their first ANC < = 16 weeks, 126 (60% controls) received four and above visits and 47(45%) cases received two visits during the study period. Also, 142(68%) controls and 94(90%) cases not experienced problems before this pregnancy (Table 2)

Table 2

Obstetric History among pregnant women in a public health facility in Bishoftu Town, Oromia, 2022.
Variables	Controls		Cases
Variables	frequency	%	Frequency	%
Number of pregnancy
One pregnancy	75	36%	44	42%
2–4 pregnancy	121	58%	58	55%
≥ 5 pregnancy	13	6%	3	3%
Number of delivery
one delivery	57	43%	29	50%
2–4 delivery	71	53%	29	50%
≥ 5 delivery	6	4%	0
History of Abortion
Yes	34	16%	19	18%
No	175	84%	86	82%
Number of ANC Visit
Two	44	21%	47	45%
Three	39	19%	32	30%
Four and above	126	60%	26	25%
Pregnancy weeks during ANC Visit
≤ 16 weeks	165	79%	66	63%
> 16 weeks	44	21%	39	37%

3.3 Knowledge of iron folate supplementation-related factors

One hundred ninety (91%) controls and ninety-six (91%) cases heard about iron supplementation during pregnancy, 208 (99.5%) controls, and 103 (98%) cases take or swallowed IFAS during recent pregnancy. In both study groups a high proportion of the pregnant women took their tablet one time per day, 110(53%) controls and 57(54%) of cases started taking IFAS before 16 weeks, 141(67%) of controls have good knowledge and 56 (53%) of cases have poor knowledge on IFAS (Table 3)

Table 3

knowledge about iron and folic acid supplementation among pregnant women in public health facility Bishoftu Town, Oromia, 2022.
Variables	Controls			Cases
Variables	Frequency	%		Frequency	%
Heard about Iron supplementation during pregnancy
No	19	9%		9	9%
Yes	190	91%		96	91%
Take or swallowed IFAS during recent pregnancy
No
Yes	209		100%	105	100%
Pregnancy weeks when started iron supplementation
Before 16 weeks	110		53%	57	54%
After 16 weeks	99		47%	48	46%
Knowledge on IFAS
Poor Knowledge	68		33%	56	53%
Good knowledge	141		67%	49	47%

3.4 Health facility-related factors

Of the total respondents, 184(88%) controls and 90(86%) cases said that it took those 30 min or less to reach the nearest health facility from their place of residence. Regarding waiting time, 156(75%) controls and 79(75%) cases of respondents wait greater than 30 minutes in the health institution. 120(57.4%) controls collected 90 tablets and 40(38%) cases collected 30 tablets, 122 (58%) controls &54 (53%) cases get IFAS from health centers, 120 (57%) controls and 54 (51%) cases no encounter shortage of supplement in the health facility (Table 4).

Table 4

Health facility-related factors among pregnant women in public health facility Bishoftu Town, Oromia, 2022.
Variables	Controls		Cases
Variables	Frequency	%	Frequency	%
Time to reach a health facility
Less or equal to 30 minutes	184	88%	90	86%
Greater than 30 minutes	25	12%	15	14%
Time to take or waiting to get health service
less or equal to 30 minutes	53	25%	26	25%
greater than 30 minutes	156	75%	79	75%
Amount of tablets collected
30 tablet collected	9	4%	40	38%
60 tablet collected	80	38%	34	32%
90 tablet collected	120	57%	31	30%
Source of IFAS
Health center	122	58%	56	53%
privet pharmacy	74	35%	42	40%
Other health facilities*	13	6%	7	7%
Shortage of IFAS in a health facility
Yes	89	43%	51	49%
No	120	57%	54	51%

3.5 Determinants of Non-Adherence of Iron Folic Acid among pregnant women

During binary logistic regression analysis, those variables with P-values of less than 0.25 were entered into multiple logistic regressions. After multiple logistic regression was conducted using the backward Wald method, five variables with p-value less than 0.05 are found, those are the age of participants, Month/weeks/ of pregnancy during first ANC, Frequency of times receive ANC, knowledge about IFAS, women who collected 30 tablets have statistically significant. The result of the study showed that the odds of non-adherence to iron-folic acid supplementation were 5 and 11.8 times more likely to happen among women aged 15–24 and 25–34 years old as compared to those aged greater than or equal to 35 years respectively [AOR = 5, 95% CI (3.04, 12.8) and [AOR = 11.8, 95% CI (18, 20.6)]. Women who had started their first ANC above 16 weeks were 4.8 times more likely to have non-adherence to IFAS than their counterparts and [AOR = 4.8, 95% CI (1.107, 5.252)]. The finding of this study revealed that those women who receive ANC visits two and three were 5.7 and 2.95 times more likely to have the odds of non-adherence to IFAS than women who received ANC visits four and above [AOR = 5.17, 95% CI 95% (2.5, 13)] and [AOR = 2.95 95% CI (1.26, 6.8)]. Those women with poor knowledge of iron folic were 3.5 times more likely to have the odds of non-adherence to IFAS than women with good knowledge. [AOR = 3.5, 95% CI (1.7, 7.2)]. Those pregnant women who collected 30 tablets and less were 7.8 times more likely to have the odds of non-adherence to IFAS than those who collected 90 tablets and above (AOR = 7.8, 95% CI (4, 18) (Table 5)

Table 5:- Determinants of Non-Adherence of Iron Folic Acid among pregnant women in a public health facility in Bishoftu Town Oromia Ethiopia 2022

Variables				Non-Adherence to iron-folic supplementation			COR (95% CI)		AOR (95% CI)		P-value
				Control		Case
Age of participants
15-24 Age		67(32.1)			39(38.1)			6( 3.6 ,14)		5 (3.04, 12.8)	0.001*
25 -34 Age		40(19.6)			57(55.2)			16(8.6 ,35)		11.8 (18, 20.6)	0.001*
≥35 Age		102(48.3)			9(6.7)			1.00		1.00	1.00
Educational status											0.095
Can’t read and write		37(17.7)			5(3.8)			0.293(,0.06 0.575)		.279 (.071 ,1.09)	0.068
Read and write		9(4.8)			17(16.1)			4(1.17, 7.2)		2.2 (.59 , 8.29)	0.232
Primary (1-8)		45(23.4)			26(21)			1.52(0.77(0.388 ,1.5)		0.6 (.250, 1.4)	0.276
secondary(9-12)		66(31.1)			33(32.4)			1.08(0.480 ,1.673)		0.639(.273 ,1.4)	0.303
diploma and above		52(23)			24(26.7)			1.00		1.00
Maternal Occupation
Government employee		35 (16.7)			22 (20.9)			1		1	1
Non-governmental employee		52(24.9)			25 (23.8)			0.765(0.34 ,1.56)		0.730(0.54 , 1.54)	0.792
Daily laborer		13(6.2)			7 (6.7)			0.857(0.29 , 2.46)		0.844( 0.35, 1.5)	0.394
Student		43(20.6)			22 (20.9)			0.814(0.81 , 1.78)		0.812( 0.28 , 2.54)	0.761
housewife		63 (30.1)			26 ( 24.8)			0.657(0.3 , 1.3)		0.645(0.34 , 1.36 )	0.588
Other(specify)***		3 (1.4)			3 (2.9)			1.591(0.29 , 8.41)		1.653(0.3 , 9.1 )	0.226
Faced problems before this pregnancy
Yes	67(32.1)				11(10.5)			0.248(0.125 ,0.494)		0.247 (.09 ,0.6)	0.005
No	142(67.9)				94(89.5)			1.00		1.00
Weeks of pregnancy during the first ANC
≥16 weeks			165(78.9)		66(62.9)		1.00			1.00
>16 weeks			44(21.1)		39(37.1)		2.2 (1.3, 3.7)			2.41(1.11 ,5.25)		0.001*
Encountered shortage of IFAS
Yes			89 (42.6)		51(48.5)		0.785 (0.49, 2.25)			1.291 (0.79, 2.24)
No			120(57.4)		54 (51.5)		1			1		1
Frequency of ANC visit
Two			44(21%)		47(45%)		5.17( 2.87 ,9.3)			5.7(2.5 ,13)		0.001*
Three			39(19%)		32(30%)		3.9 ( 2.1,7.46)			2.95(1.26 ,6.8)		0.01*
Four & above			126(60%)		26(25%)		1.00			1.00		1
knowledge about IFAS
good knowledge			141(67%)		49(47%)		1.00			1.00		1
poor knowledge			68(33%)		56(53%)		2.370(1.466, 3.831)			3.5 (1.7, 7.2)		0.001*
Health Extension worker visits pregnant women
Yes			158 (75.5)		84 (48.5)		1			1		1
No			51 (24.4)		21 (20)		1.291(0.79 , 2.2)			0.814 (0.54, 1.84)
Face side effects of IFAS
Yes			73 (34.9)		37(17.7)		1.08 (0.64, 1.84)			1 (0.65, 1.65)		0.92
No			136 (65.1)		68(32.5)		1			1		1
Health care provider counseled about IFAS
Yes			137 (65.5)		67(63.8)		1			1		1
No			72(34.4)		38(36.2)		1.079 (0.66,1.76)			0.905 (0.54, 1.54)		0.7
IFAS Tablet Collected
30 tablet collected			9(4%)		39(37%)		16.7(7.3 ,38.3)			7.8 (4.0, 18)		0.001**
60 tablet collected			80(38%)		34(32%)		1.6(0.9 , 2.9)			1.5 (0.60, 3.5)		0.29
90 tablet collected			120(57%)		31(30)		1.00			1.00

AOR=Adjusted Odds Ratio, COR= Crude Odds Ratio, CI=Confidence Interval, (*) statistically significant at p-value<0.05, 1= Reference group

The study aimed to identify determinants of non-adherence to iron-folic acid supplementation among pregnant women attending antenatal care in public health facilities in Bishoftu town, Oromia region. In this study the identified determinants of non-adherence to iron-folic acid supplementation were; the age of respondents, pregnancy weeks during the first ANC visit, Frequency of ANC visit, knowledge about IFAS and amount of tablet collected have statistically significant.

This study revealed that maternal age was significantly associated with IFA supplementation. Those respondents with age categories of 15–24 years and 25–34 years were 5 and 11.8 times more likely to non-Adherence to IFAS than those aged greater than or equal to 35 years respectively. The finding of this study is consistent with the study conducted in Kenya (6), that age of the pregnant woman is closely related to the woman which has also been cited to be a factor in utilization of IFA supplements. Young and teenage pregnant women lack Knowledge of the benefits of IFA supplements, older women start their ANC early since they assume that they have a great level of experience, and increased age is reported to be associated with IFAS compliance. This might be due to poor counseling and less adherence and follow-up on supplements upon teenage. This finding is inconsistent with the study done in Pakistan (42), according to a study conducted in Pakistan high number of non-adherence were aged above 45 years and similarly, the study done in Ethiopia showed that women above 35 years of age had 4 times more likely higher odds of non-adherence to IFAS (14). Also, a study done in Adwa town, Tigray region of Ethiopia contrasts with this study age of 25–29 years that the pregnant mothers were also found to be associated with adherence to the iron-folic acid supplement. The odds of adherence to folic acid among pregnant mothers in this age group of 25–29 years were two times higher than those who were in the age group of greater than 35 years (21).

Pregnant women who started their first ANC at greater than 16 weeks were 2.4 times more likely to non-Adherence to IFAS than their counterparts. This finding is in line with the study done in Central Ethiopia (43), Lay Armachiho Northwest Ethiopia (37), and at Hosanna Town of Southern Ethiopia (18). A study done at Tikur Anbessa specialized hospital showed that Gestational age at the first ANC visit was significantly associated with adherence to IFAS.

Thus, pregnant women who started their ANC follow-up in the first trimester were 1.87 times more likely to Adherence to IFAS (26). And also this study is in line with a study done in Lay Armacho town that showed 60% of women who didn’t early register for ANC visits had non-adherence to IFAS (8). Mothers who were registered early for ANC were 73.3% in this study and the study conducted in the North Wollo Zone of Northern Ethiopia showed that 57% have early ANC registration which has the chance of more ANC visits throughout their pregnancy. This may be helpful for them in obtaining more knowledge regarding iron deficiency anemia and the benefit of iron and folic acid supplementation than other pregnant women as well as they receive counseling from healthcare providers during their long ANC visits (27).

It is recommended that the first contact of the pregnant woman with the ANC be made within the first trimester of pregnancy. Therefore, early ANC attendance enables nutrition counseling of pregnant women that may improve knowledge on IFA supplementation and hence increases adherence to IFA consumption (6). The reason might be that pregnant women who start their ANC follow-up greater than 16 weeks have fewer ANC contact and poor knowledge of iron folic supplementation; these may lead to poor adherence to IFAS.

According to this study, pregnant women who had received ANC visits two and three were 5 and 2.9 times more likely to have non-adherence to IFAS than women who received ANC visits four and above visits. This finding is supported by the study conducted in Wolaita, South

Ethiopia that a women who visited 2 and 3 ANC visits had 78% reduced odds of using the supplementation, respectively (29). Similarly, the study is consistent with the study done in south Ethiopia (14), North Wollo Zone of northern Ethiopia (21), and Senegal (22). This might be due to information about the importance of iron folic supplementation provided by health professionals and the number of ANC contacts that influence the adherence status of pregnant women to the supplement because pregnant women receive iron supplementation through ANC visits at health facilities.

Also, the study revealed that pregnant women with poor knowledge were 3.5 times more likely to have non-adherence to IFAS than women with good knowledge. This finding is in line with a study done in Aykel town, Northwest Ethiopia that showed those women who had poor knowledge of IFAS were more likely to be non-adhered as compared to those who had good knowledge of IFAS (32). Those pregnant women who know about iron folic supplementation have a direct relation with non-adherence to iron-folic and maternal education with secondary and above were contributing factors for iron folic supplementation (33).

The study also showed that pregnant women who collected 30 tablets of iron folic were 7.8 times more likely to have non-adherence to IFAS than those who collected 90 plus iron folic tablets. The finding is inconsistent with WHO recommendation (10), but the non-adherence to iron-folic in the current study is in line with the results of the study conducted in Northwest, Ethiopia. This discrepancy may be due to a shortage of iron folic and unavailability of drugs (stock out), unable to take the supplement because of different reasons, and poor adherence during each visit.

4.1 Strengths and limitations of the study

This study identifies or establishes the temporal relationship between case and control using wealth index rather than economic status. As a limitation of the study, the information on non-adherence to iron-folic acid supplementation was from self-report (electronic and pills counting method was not used) and the study may have recall and social desirability bias.

The findings from this study were assessed and identified different determinants of non-adherence to iron-folic acid supplementation among pregnant women attending antenatal care in public health facilities. Of all assessed determinants of iron-folic acid supplementation; the age of pregnant women, frequency of ANC visits, weeks of pregnancy during starting first ANC, and poor knowledge of pregnant women were the identified factors for no-adherence to iron-folic acid supplementation.

The town health office should work on non-adherence to iron-folic acid supplementation by strengthening antenatal care services with the frequency of visits through health education and ANC counseling activities to improve maternal knowledge and awareness of pregnant women on iron adherence. Encourage and facilitate the availability and distribution of iron folic acid to overcome the shortage of IFAS. Health professionals should work on transferring appropriate health information to pregnant women about the importance of adherence to iron-folic acid and empowering the women's development army to educate pregnant women through a health extension program on IFAS to initiate pregnant women for early ANC follow-up with its recommended frequency of visits, the correct dose and amount of tablet intake.

ANC: Antenatal Care, AOR: Adjusted Odds Ratio, CI: Confidence Interval, FA: Folic acid

IFAS: Iron and Folic acid supplementation, NTD: Neural Tube Defect, PI=Principal Investigator, SPSS: statistical package for social sciences, WHO: World Health Organization.

Ethical approval and consent to participate

The ethical approval was obtained from Salale University, College of Health Sciences ethical review committee, and a letter of permission was obtained from the Bishoftu town health office and respective Hospitals and Health Centers before conducting the study based on the Declaration of Helsinki. The ANC clinic staff was informed about the purpose of the study and written informed consent was obtained from every pregnant woman who attended the ANC visit and for the age of the mother less than 18 years the informed written consent to participate in the study were obtained from their parents/legal guardians. The entire study participants were informed that data was kept private, confidential, and used only for research purposes. Participation was voluntary and they were told that they can withdraw from the study at any time of data collection.

Consent to publication

Not applicable

Availability of Data and Materials

All the data sets generated during and/or analyzed during the study are included in the study and available from the corresponding author upon reasonable request.

Conflicts of interests

The authors declared that they have no conflicts of interest.

Funding

The study was funded by Salale University on behalf of Oromia Health Bureau (OHB) sponsorship

Author Contributions

AHG, LA, and TN participated inconceptualization, data curation, formal analysis, investigation, funding acquisition, methodology, project administration, resources, software, supervision, validation, visualization, writing the original draft, writing a review, and editing the manuscript. DG, BSD, HD, EL, DI, and LAparticipated inconceptualization, data curation, investigation, methodology, project administration, software, supervision, validation, visualization, writing the original draft, writing a review, and editing the manuscript. Finally, all of the authors reviewed the final manuscript and approved it for submission.

Acknowledgement

First, we would like to express our deepest gratitude to Salale University, College of Health Sciences for providing us the opportunity to participate in this research work activity. In addition, we would like to extend our heartfelt gratitude and thanks to all data collectors, supervisors, study participants, and the Bishoftu Town Health Office for their kind support in providing valuable information during conducting this study.

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No competing interests reported.

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Determinants of non-adherence to Iron Folic Acid Supplementation among Pregnant Women Attending Public Health Facilities in Bishoftu Town, Ethiopia: Case-Control study

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Abstract

Figures

1. INTRODUCTION

2. METHODS AND MATERIALS

2.1 Study Design, Period, and Area:

2.2 Source and study population:

2.3 Eligibility criteria

2.4 Sample size determination

2.5 Sampling procedure

2.6 Data collection tool and procedures

2.7 Study variable

2.7.1 Dependent Variable

2.7.2 Independent Variables

2.8 Operational definition

2.9 Data quality assurance

2.10 Data processing and analysis

3. RESULT

3.1 Socio-demographic characteristics of respondents

3.2 Obstetric History of pregnant women

3.3 Knowledge of iron folate supplementation-related factors

3.4 Health facility-related factors

3.5 Determinants of Non-Adherence of Iron Folic Acid among pregnant women

4. DISCUSSION

4.1 Strengths and limitations of the study

5. CONCLUSION

6. RECOMMENDATION

Abbreviations

Declarations

References

Additional Declarations

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