An institutional based unmatched case control study was conducted to identify the determinant factors of adherence to iron-folate supplementation on 240 postnatal mothers in three referral hospitals in Addis Ababa, Ethiopia.
This study was conducted in three referral hospitals of Addis Ababa, namely Zewditu Memorial Hospital (ZMH), St. Paul’s Hospital (SPH) and Gandhi Memorial Hospital (GMH). Addis Ababa is the capital city of Ethiopia. The latitude of Addis Ababa is 9.005401, and the longitude is 38.763611.7 Based on the 2017 population projection, the total Population of the city is 3,273,001, among which 1,772,001 are women and 1,551,000 are men. According to Ethiopian Demographic and Health Survey (EDHS) 2011, the coverage of antenatal care (ANC) services, birth assistance by skilled provider, and postnatal care in the city were 93.6%, 83.9%, and 47.7%, respectively.8
Source and study population
The source population for this study was all women who were attending postnatal care (PNC) follow up at the three referral hospitals, i.e., ZMH, SPH and GMH, in Addis Ababa, Ethiopia. Participants of the study are postnatal mothers who were attending PNC follow up at the three hospitals during the study period. The 240 randomly selected mothers who also fulfilled the inclusion criteria were the study population.
Inclusion and exclusion criteria
The inclusion criteria were postnatal mothers who attended their PNC follow up in the three referral hospitals during the study period. However, mothers who were critically ill during the study period and whose gestational age was below 37 weeks (i.e. preterm delivery) were excluded from the study.
Sample size determination and sampling procedure
The sample size was calculated using Epi Info, considering 95% confidence level (CI), 80% power, control to case ratio of 2, minimum odd ratio (OR) of 2, and 10% non-response gave a minimum sample of 82 cases of adherence and 164 controls.
As mentioned in the preceding sections, the study was conducted in three referral hospitals of Addis Ababa, namely ZMH, SPH and GMH. The number of participants per hospital was allocated based on the average number of mothers who attend PNC follow up per year. Previous PNC follow up per year for ZMH, SPH and GMH were 2471, 2580 and 974, respectively. Based on this data and the sample size of the study, the participants of each hospital were selected using a systematic random sampling method with intervals of two.
Antenatal service: Pregnancy check-up by health personnel, provision of iron/folic acid supplements, tetanus vaccination and health education and counseling.
ANC follow up: A woman who had regular antenatal care four times during pregnancy period.
Cases: For this study, cases are women who took 90+ tablets during pregnancy period.
Controls: Controls are women who took less than 90 tablets during their pregnancy period.
Adherence: Mothers are said to be adhered to IFA supplement if they took 90 or more supplements during their pregnancy period.
Non-adherence: Pregnant mother is said to be non-adherence to IFA supplement if they took less than 90 tablets during their pregnancy period.
Trimester: The number of weeks during pregnancy (1st, 1-12 weeks; 2nd, 13-26 weeks; 3rd, 27-40 weeks).
Gravidity: The number of pregnancies, whatever is the outcome.
Parity: The number of live births among the pregnancies.
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.
Close family member: Are individuals who are related by blood, which includes grandparents, parents, siblings and children.
Dietary diversity score: Number of food groups consumed in the previous day. It is categorized as low dietary diversity (≤ 3 food groups), medium dietary diversity (4 to 5 food groups) and high dietary diversity (≥ 6 food groups).
Knowledge: From the knowledge questions asked, those who correctly answer less than two questions are considered to have poor knowledge and those who correctly answer more than two questions are considered to have good knowledge.
Data collection and Analysis
The data collection instruments were questionnaire contents included socio-demographic, obstetric history, health facility and knowledge related variables, dietary and nutritional factors, and pre-conception related variables. Women who took more than 90 tablets were considered to have adhered to the supplementation.
The questionnaire was pretested on 12 women of similar population at Tikur Anbesa hospital in Addis Ababa. Data were collected and supervised by six nurses (all holding Bachelor of Science degree). Both data collectors and supervisors were trained on how to collect the data and how to use the data collection instruments. The supervisors checked the completeness of the data every day.
The collected data were entered, coded and cleaned using EpiData version 7.2, and the data management and analysis were performed using SPSS version 20.0 software. Socio-demographic, obstetric, heath faculty and knowledge related variables, dietary and nutritional factors, and pre-conception related factors of women were presented in text and tables. Bivariate analysis was done and variables with less than 0.25 P-values were included in the multiple logistic regression analysis. In the multivariable analysis, predictors with P-value less than 0.05 were considered statically significant.