Adherence rate to iron folic acid supplementation among pregnant women

Introduction Globally 41.8% of pregnant women are anemic with the highest proportion affected in developing countries. Nationally, only 0.4% of the pregnant women take Iron supplements more than 90 days of the recommended 180 days. In Oromiya region 75.3% of pregnant women do not take any iron tablets or syrup during their last pregnancy, while 10.8% take for less than 60 days, 0.4% took for 60-89 days and only 0.3% took for 90 days or more. Objective To assess the adherence rate to iron and folic acid supplements among pregnant women attending antenatal clinics in Asella Town, south east Ethiopia Method and materials Institution based cross-sectional quantitative study design was conducted in Asella town from September 2015 to June 2016. A purposive sampling technique used to select the health institution. There are six health institutions selected for this study. The sample size 317 was selected with systematic random sampling method. Ten percent of pre-test was conducted in one institution which is not included in data collection. Data were collected using structured pre-tested questionnaire. Before data collection verbal consent was obtained. The collected data were analyzed using Epi-data and SPSS version 22.00 packages. Result The study revealed that Out of 317 pregnant women 296 (93%) responded to the questioner. The study revealed that 177 (59.8%) of pregnant mothers in the town adhered to the iron/folic acid supplement. Conclusion and recommendation Adherence of iron/folic acid supplementation found in this study is very low. Consequently, maternal education, adequate supplement supply to the health facility, early starting antenatal visit, and health education on duration of supplementation


Introduction
Iron deficiency anemia is the most common nutritional disorder affecting two billion people worldwide (1). Based on evidence from iron supplementation trials, it was estimated that, on average, 50% of anemia globally is caused by iron deficiency (2). Pregnant women are at especially high risk of iron deficiency and anemia because of significantly increased iron requirements during pregnancy. Iron supplementation has been a major strategy in low-income and middle-income countries where micronutrient deficiencies are common to reduce iron deficiency anemia in pregnancy (2,3).
Globally 41.8%, almost half of all pregnant women are anemic with the highest proportion affected in developing countries. The prevalence of anemia among pregnant women in developed country is 18% in average, which is significantly lower than the average 56% in developing countries. The actual prevalence of anemia in pregnant women in Africa and Asia is estimated to be 57.1% and 48.2%, while that of America and Europe is 24.1% and 25.1% respectively (4,5).
Currently seventeen percent of Ethiopian women age 15-49 are anemic with the highest proportion of pregnant women (22%) than breast feeding (19 %) and neither pregnant nor breastfeeding women (15 %). Anemia prevalence also varies from urban and rural residence; a higher proportion of women in rural areas are anemic (18 %) than those in urban areas (11 %) (6).
The 2011 EDHS revealed that maternal nutritional status is poor in many respects in Ethiopia. Out of 17% of anemic women, 13% of them have mild anemia where hemoglobin level range g/dl and 9.9 g/dl, and 1% having severe anemia where Hgb level is <7 g/dl. (6,7,8).
Ethiopia, like most sub-Saharan Africa countries, has a national policy to prevent and treat anemia in pregnancy. This includes the provision of ferrous sulfate and folic acid to all pregnant women. The recommended dose in Ethiopia is 300 to 325 mg (milligrams) of ferrous sulfate and 400μg of folic acid once a day taken by mouth for 180 days of prenatal period, preferably with a meal. This dosage is usually supplied in a single combined iron and folic acid tablet (9).

Study area
The study was conducted in Asella town south east Ethiopia. It is located in the Arsi Zone, Oromia Region about 175 kilometers from Addis Ababa. The current total population for Asella town is reported as 93,729, of whom 47,801(51%) were men and 45,927(49%) were women. Out of the total population 20,714(22.1%) of them were in reproductive age group. The majority of the inhabitants said they practiced Ethiopian Orthodox Christianity, with 67.43% of the population reporting they observed this belief, while 22.65% of the population were Muslim, and 8.75% of the population were Protestant.
Azalea town comprises governmental (teaching and referral hospital and two health centers), nongovernmental (13 medium clinic, one hospital, one specialty MCH center and one higher clinic), nonprofit nongovernmental (FGA and Marie stops). Out of these 21 health institution eight of them comprise antenatal clinic out of which seven of them only provide a regular ANC check up.

Study and Data collection period
The study period was from September 2015 to June 2016 and data collection period was April 1 st to 30 th , 2016.

Study design
Institutionally based cross-sectional quantitative study design was conducted, to determine the adherence rate to Iron-folate supplements among pregnant women in Asella town.

Source population
The source population of the study was pregnant women attending ANC clinics in health institutions in Asella town.

Study population
The study population was pregnant women attending ANC clinics in selected health institutions during the data collection period and that fulfill the inclusion criteria.

Inclusion criteria
Pregnant women who had at least one ANC visit in health institution and supplemented with IFA tablets for at least one month before the date of interview.

Exclusion criteria
Pregnant women who come for the first antenatal visit, those who refuse to take the supplement, those mistakenly not provided the supplement, those who are unable to hear and/or speak and those who have mental disorder were excluded.

Sample size determination
The sample size of this study was calculated by using the formula to estimate a single With the assumptions of the 95 % confidence interval, 10% non responsive rate the total sample size will be 317.

Sampling procedure and technique
All health institutions (private and public) in Asella town were included in order to make the data representative. The health institution was selected with purposive sampling because the researcher was interested only on those institutions which provide regular ANC check up and a total sample size 317 pregnant women was selected using systematic random sampling as shown on the figure 1. The total estimated number of pregnant women attending antenatal clinics in each antenatal institution for a single month was taken and proportional sample size was calculated for each institution so as to give the total sample size by using the following formula. week considered to be adhered to the supplementation (6).
 Non-adherence: Pregnant women who had taken combined iron/folic tablet for less than 4 days a week considered to be not adhered to the supplementation (6).
 Anemia: Pregnant mother hemoglobin (Hgb) level in the blood is less than 11g/dl, which depicts decreased oxygen-carrying capacity for pregnant women. Before the actual data collection, the questionnaire was pretested on 10% of similar population in Asella medium clinic to check the consistency and reliability. Data collector and supervisor were trained prior to conduct the data collection. After pretest some correction made to the questioner.
Five diploma Nurses were recruited as a data collector and two BSc nurses were assigned for a supervisor, they were checking the data every day after data collection for the completeness of the questionnaire. Training was given to data collectors and supervisors for two days on purpose, of the study, details of the questionnaire, data collection procedure and filling the questioner.

Data processing and analysis
The collected data were cleaned and checked for completeness; it was entered, compiled and analyzed with Epi data and SPSS version 22.00 packages. A univariate, was done using frequencies, to show adherence rate of iron and folic acid supplementation. Statistical significance declared at p-value less than 0.05.

Ethical consideration
Ethical clearance was obtained from department of nursing and midwifery institutional ethical committee, school of allied health, College of Health Science. From the Department of Nursing and Midwifery the permission letter was written to Oromia regional health bureau to conduct the study and, then the permission letter was obtained from Oromia regional health bureau for the different study area to conduct the study. Finally informed verbal consent was obtained from each respondent. Information sheet and information was provided to the study participants about objective of the study. The response confidentiality was maintained.  When the respondents were asked if they had any history of birth complications such as stillbirths and abortion, 3.7% and 24.3% confirmed they had a history of stillbirth and abortion respectively while 96.3% and 75.7% did not have a history of asked complications. Majority 90.9% and 94.6% of women did not experience anemia neither in previous nor in current pregnancy ( Figure 2).

Fig 2: Previous and current history of anemia of the study women, Asella town, 2016
The great majority of interviews pregnant women [76%] and [50.7%] were knowledgeable about iron, folic acid and anemia respectively in giving the correct answer from listed correct and incorrect response to questions asked to type, duration, benefit and risk of IFA and cause, consequence, prevention of anemia and most susceptible group of people for anemia. While half, 49.3% of respondent mother were unable to give correct answer from listed correct and incorrect response to questions asked on anemia and Around one-quarter (24%) of the respondent mother fail to give correct answer from listed correct and incorrect response on iron and folic acid   Adherence, which was considered as having taken a tablet of iron/folate supplements for four or more times in a week was observed by 177(59.8%) of the respondents, while 119(40.2%) had not adhered to the supplements (as shown in figure 5).

Discussion
The adherence rate of iron and folic acid supplement found in this study is 59.8%, this result was consistent with studies done in the city of Mangalore, India, which was 62% and also consistent with the result found from cross-sectional study done in urban slums at Nagpur city, Maharashtra, India, which was 61.7% compliance. This consistency may be due to study were urban based and the pregnant women may get information from the health center, it may be due to health center accessibility (17,30). Study done in Ethiopia, Oromia region, which shows adherence rate 0.3% is not consistent (6). In fact this study was done in urban areas and the women were probably more educated than those in rural areas could have contributed to the higher level than the regional level.
Iron/folic acid Adherence rate found in this study, 59.8% also higher than study done in Ethiopia, mecha district Amhara region result found was 20.4% (22). This difference in compliance may be due to the time gap, the culture of the people and different geographical location. And also cross-sectional study found in rural Kenya about adherence rate for optimum supplementation 90+ days was 18.3%. This difference is due to a study done in a rural set up, educational status, knowledge about supplement and access to the supplement are very low (19).
In addition, result of adherence found in this study was lower than result found in eight rural districts in SNNP, Ethiopia, 2014 which was 74.9% average level of adherence rate of pregnant women in the area. This inconsistency may be due to cultural, geographical location and availability of drugs in the health center (16).

Acknowledgment
First of all, I would like to express my deepest gratitude and appreciation to my advisor Rajalakshmi Murugan for her unreserved all rounded, support and enriching comment throughout the research thesis.
I would like to thank the department of nursing and midwifery, Addis Ababa University for giving this chance to prepare this research project. My appreciations also go to all staffs of school of nursing and midwifery for their unreserved support throughout the course and thesis works.
Finally, I would like to express gratitude for Asella Town Administrative Health office, the selected health institution in Asella town for providing the necessary information, the data collectors, supervisors and all participants who took part in this study.