Compliance to iron folic acid consumption and factors associated among antenatal care attendant mothers in southern Ethiopia

Abstract

Iron and folic acid (IFA) consumption is an important strategy for the prevention of birth defects and anemia during pregnancy. In Ethiopia, low proportion of pregnant mothers took an iron tablet for 90 plus days. Therefore, the aim of this study was to assess compliance to IFA consumption and its associated factors among mothers attending antenatal care in Southern Ethiopia, 2021. An institution-based cross-sectional study triangulated with qualitative methods was conducted. The data was collected data from 378 respondents selected by a simple random sampling technique and 21 in-depth interviews were conducted. Epi Data version 3.1 was used to enter data, which was then exported to Statistical Package for the social Science (SPSS) version 21 for further processing and analysis. Bivariable and multivariable logistic regression analyses were carried out to identify the significant association. Variables with a P-value of less than 0.05 were considered significant. The Open code software version 4.03 was used to code and categorize qualitative data, and then thematic analysis was employed to qualitative data. The compliance rate of IFA consumption was 66.58% 95% CI: 61.5-71.4%) Maternal education (AOR: 3.01, 95%CI:1.29, 6.35), knowledge about anemia (AOR: 2.63, 95% CI:1.29), 5.37), knowledge about IFA (AOR: 2.95, 95% CI (1.45, 6.02)), ANC visits (AOR: 2.70, 95% CI 1.17, 6.22), fear of side effect (AOR: 0.08, 95% CI:0.02, 0.24), registration time for initiation of ANC visits (AOR:4.63, 95% CI:1.50, 14.26), and counseling on IFA (AOR:3.95, 95% CI:1.57, 9.98) were significantly associated with compliance IFA consumption of the pregnant mothers. Supplement-related, pregnancy and experience-related, facility related, behavioral -related, perceived family support, and perceived cultural belief findings were identified from qualitative study. In this study, the compliance with IFA consumption was low and influenced by huge range factors. To improve compliance with IFA, health workers provide proper counseling and education for pregnant women on IFA and follow up supplementation.

Introduction

Iron and folic Acid (IFA) is an important micronutrient for physiological function, growth, and development in saving the mother and fetus during pregnancy and after delivery^1,2. IFA is a trace element that is required for hemoglobin synthesis and plays critical role in oxygen transport, cytochromes, the mitochondrial electron transport chain, and cellular metabolism³. It is also metallo-proteins, which are essential for DNA synthesis, steroid and hormone synthesis, cell proliferation, gene regulation and differentiation, a neutrophil respiratory burst of phagocytosis, and drug metabolism⁴.

During pregnancy, demand for IFA increase to meet the daily nutritional requirement for development and growth of the fetus during pregnancy throughout gestation^1,2. Anemia is a worldwide public health challenge that primarily affects the developing counties, and raises serious concerns about societal health and economic development⁵. Anemia globally affects about 1.62 billion people, corresponding to 25% of the global population. 38% of pregnant women worldwide are anemic, with the highest magnitude in Africa (62.3%) followed by South East Asia (53.8%)¹. In Ethiopia, according the Ethiopian Demography and Health Survey (EDHS) 2016 reported that 29% of pregnant women are anemic⁵.

IFA deficiency is a public health concern worldwide, particularly in low income and middle-income countries^1,2. IFA deficiency related anemia is the most common causes of anemia in pregnancy, responsible for 50% of anemia^1,6.

To prevent and control iron deficiency anemia, many developing countries, including Ethiopia, have implemented various interventions and programs during pregnancy. One the main interventions strategy is provision of IFA to all pregnant women free of charge. Consequently, the Ethiopia National Nutrition Program II (2016–2020) set a key target of increasing the proportion of mothers consuming IFA supplements for 90 and more days during pregnancy and postpartum period^7–9. IFA consumption is crucial for the minimizing of birth defects and anemia during pregnancy^7,8. Non-compliance with IFA consumption during pregnancy has a potential negative impact on the health of both mother and the fetus. Increased compliance to IFA consumption during pregnancy is associated with a lower risk of maternal anemia, hemorrhage, newborn disease, and fetal anomalies^1,10.

IFA compliance refer to the extent to which pregnant women comply to take medication or the condition of sticking to the dose and time for taking IFA as prescribed by health care providers or per recommendations¹¹. According to World Health Organization (WHO) and Ethiopian guideline, a pregnant woman is expected to take 90 days and more IFA supplements on daily basis during pregnancy¹². However, compliance of pregnant women to IFA is one challenge to prevent anemia during pregnancy, as it is unexpectedly low.

According research findings, overall compliance with IFA supplementation among pregnant women is 64.7% in India and 65.9% in Nigeria^13,14. Different studies in Ethiopia revealed that the compliance level among pregnant women to IFA ranging 2-60% with specific proportion of 18% in southeast Ethiopia¹⁵, 53% in Dembia¹⁶, 55.5% northwest Ethiopia¹⁷, and 60% in Jimma Town¹⁸, 22% in Dire Dawa, 19% in Addis Ababa, 2% Somalia 4% southern Ethiopia¹⁹. Although the proportion of pregnant women taking iron supplements for 90 days or more increased from 5% in 2016 to 11% in 2019, it but remains at low level from standard^5,19.

The contributing factor for compliance includes maternal educational status, early registration in antenatal care (ANC) before 16 weeks, frequent ANC visits (4 times or more), knowledge about anemia, having anemia during the current pregnancy, having knowledge on advantage of IFA, and getting health education about the advantage of IFA²⁰.

In Ethiopia, data on the compliance level among the pregnant women are self-report of IFA intake. There is the possibility of over or lower reporting IFA consumption among pregnant women who did not actually ingest the tablets²¹.

Regardless of having many studies done in different parts of the Ethiopia, most of the studies were based on a short period (seven-day IFA intake), on self-reported IFA intake, the rate of compliance varies, most of studies were community based determinates and it overlooked institutional related factors, factories associated were varies across studies, and also the level of education, cultural practices, the strength of health service, and social support vary from place to place^18,20,22.

Moreover, there is paucity studies on compliance with IFA among mother attending ANC through tablet count by triangulated with qualitative method. As to best our knowledge, there is no study examined compliance level among pregnant women in Anlemo wored, Hadiya zone. Identifying influencing factories is not enough to take appropriate intervention to improve compliance level of IFA among pregnant women since compliance to IFA consumptions affected by huge factors like facility related factors, supplement related, perceived beliefs and personal experience. Current study determines compliance level of IFA consumption among pregnant women by employing tablets counting and mixed study in study area. This aims to assess compliance level of IFA consumption and its associated factors among ANC attending pregnant women, and to explore personal experience, barriers and facilitators for compliance to IFA consumption in Anlemo woreda, Hadiya Zone, southern Ethiopia.

Methods and materials

Study setting

The study was conducted in Anlemo woreda of Hadiya Zone, southern Ethiopia. It is located 215 km away from Addis Ababa, the capital city of Ethiopia. The study area has 28 kebeles with a total population of 95,719 (Males 48.2% and Females 51.8%). The estimated number of pregnant women in the woreda is 3312. The woreda has 33 health institutions (28 health posts and 5 health centers). The estimation of pregnant mothers constitutes 3.46% of the total population. Common foods consumed in the area are Teff injera and Shiro wot, wheat bread, and Inset products. Agriculture is the main occupation of the people of the study area. This study was conducted from June 15-July 15/2021.

Study design

An institutional-based concurrent mixed-method triangulated quantitative and qualitative method.

Population

Source population

Quantitative: All pregnant mothers attending ANC service; and those supplied with an IFA supplement.

Study population

Randomly selected pregnant mothers attending ANC and those supplied with an IFA supplement.

Qualitative

The study populations were selected to explore the perceived experience, barriers and facilitators to compliance, and perceived belief in IFA consumption to enrich and enhance the credibility of findings. For the qualitative study participants were selected purposively from pregnant attending ANC and health workers working in maternal unit.

Inclusion and exclusion criteria

Pregnant mothers who have been attending ANC for at least one month prior to the study period and have been received IFA were included in the current study. Pregnant women who were unable to respond or very sick were excluded.

Sample size determination and sampling procedure

The sample size for the first specific objective was determined by a computer-based on Epi info 7 software Stat Calc using a single proportion for compliance of IFA P= 53%¹⁶, at 95% confidence level, 5% margin of error, source population (N = 3312), final sample(n_f) = 344. So the final sample size for this study was 344+ (344*10%) = 378.

All health centers in the woreda were included in the study. A proportional allocation of total sample size (n = 378) to each health center was as follows: Fonko, Achamo, Bandalicho, Anagero, and Meirab homa health centers were 1127 (n = 129), 558(n = 64), 449(n = 51), 582(n = 66), and 596(n = 68), respectively. The final sample size was allocated proportionally for each health center based on the number of pregnant mothers attending ANC who are supplement IFA by using the list of ANC registration books as the sampling frame. Finally, the study participants were selected by using a simple random sampling method.

Qualitative: A purposive sampling method was used to recruit study participants based on delivering depth information on personal experience, barriers and facilitators, and perceived belief on IFA consumption for in-depth and key informant qualitative interviews. A total of 21 participants were recruited for qualitative interviews. A total of 16 pregnant women, both compliant and not compliant, were ANC attending and supplemented with IFA were recruited for in-depth interviews, and 5 healthcare workers who were working at the maternal unit were recruited for key informant interviews. To ensure data saturation and sample size adequacy for qualitative study for capturing the breadth and depth of the research questions, we analysed data after each interview and continued data collection until no new information or themes emerged.

Operational definitions

Compliance

pregnant mothers were considered to be compliant with an iron-foliate supplement if they took at least 70% of the expected dose of the iron foliate tablets based on one tablet per day in thirty days of the previous month of the study, which is equivalent to consuming at least twenty one tablets per month by counting of remaining tablet. During the follow-up visit, each subject’s compliance was computed and classified as either noncompliance (i.e. <70% of tablets ingested) or compliance (i.e. ≥70% of tablets ingested). The level of compliance was assessed based on the counted number of pills doses taken in the preceding 30 days of the survey²³.

Knowledge of anemia

what the individual knows about signs and symptoms, causes, consequences, and treatment of anemia. A composite variable was created by summing up all relevant 18 knowledge items (4 items on signs and symptoms of anemia; 6 items for causes; 6 items for consequences of anemia during pregnancy, 2 items on treatment of anemia during pregnancy. A correct answer for each item was scored as “1” and an incorrect answer was scored as “0”. Then items were summed up. Answers were categorized into two groups; those who scored median and above were considered as have good knowledge and poor knowledge when scored below median²⁴.

Knowledge of the importance of IFA consumption

what the individual knows about the importance of IFA consumption during pregnancy and possible effects of IDA deficiency. A composite variable was created by summing up all relevant 8 items (3 items on importance of IFA consumption and 5 items on possible effects of IFA deficiency anemia during pregnancy). ‘Yes’ answer for each item was scored as “1” and a ‘no’ answer was scored as “0”. Then items were summed up. Answers were categorized into two groups; those who scored median and above were considered as have good knowledge and poor knowledge when scored below median^24,26

Counseling of IFA consumption

Includes benefits of taking IFA during pregnancy for fetus and mother, daily and timely taking of IFA pills, side effects and its management, and dietary source of iron, effects of iron-deficiency during pregnancy.

Data collection tools and procedure

Quantitative

Data were collected through face-to-face interviews by using a pretested structured questionnaire. The questionnaire was prepared after reviewing the literature. The data collectors were by five nurses, and supervised by two public health officers. Two days training was given for both data collectors and supervisors on data collection instruments, interview techniques, and the importance of taking informed consent before data collection starts and objective study. Each day, collected data was checked for completeness and its consistency by supervisors and researchers.

Qualitative

Pregnant women and health care workers were recruited for in-depth interviews and key informant interview that qualitative part of the study. An in-depth interview guides with multiple probing were prepared in the English language for both pregnant women and key informants the translated into the local Hadiyisa language by language expert to address perceived personal experience, perceived barriers and facilitator related, perceived belief and perceived social support. An in-depth interview was conducted with purposely selected pregnant mothers and key informants health care workers by the investigator. And interviews were held in a quiet and comfortable place. The interviews were recorded via a tape recorder and notes also taken.

Data quality control

Data collectors and supervisors were trained. The tool was pretested in the Lemo wored among study participants 5% of the total sample size. Corrections to question ordering and avoiding jargon terms were made after the pre-test of tools. The English version of the questionnaire was translated into Hadiyisa and back to English by different language experts. Closer supervision was undertaken during data collection. The data was cleaned for outliers, missing values, incompleteness, and inconsistency.

Peer examination was used to ensure the truthworth of the qualitative data. The research assistants employed had experience in qualitative research. In the debriefing of the collected data, the study participant’s demography was described in detail; included different groups (compliant and non-compliant pregnant women from rular and urban, educted and not formal educted) and healthcare worker were also included which helps to ensure cridiblity finding and to include voice of stakeholder. Audio tapes of in-depth interviews were recorded and stored in a password-locked file folder and could be made available for any reasonable third-party checkup. To ensure overall trustworthiness (credibility, dependability, transferability, and conformability) was maintained throughout the study.

Data analysis

Quantitative

After checking completeness and cleaning, data was entered into Epi-data version 3.1 and analyzed using SPSS Version 21. %ages and frequencies were used to summarize categorical variables. The results were presented by tables, texts, and graphs based on the nature of the variable. Binary logistic regression analysis was used to determine the association of independent variables with a dependent variable, IFA. The Variables significant in binary logistic regression with a p-value < 0.25 were considered for multivariable logistic regression analysis. To demonstrate the strength of the association, crude odds ratio (COR) and adjusted odds ratio (AOR), together with the 95% confidence interval, were calculated. Variables having a p-value of 0.05 or lower were considered statistically significant in the multivariable logistic regression analysis. The multi-collinearity was checked among selected independent variables via variance inflation factor (VIF) which is less than 10. The goodness of fit of the final model was checked by Hosmer and Lemeshow (0.324) was found fit.

Qualitative

Qualitative data were analysed using thematic analysis. Audio and field note data were transcribed word by word and then translated to English after the interview ended by experts for analysis. All transcript data were repeatedly read by all authors to familiarize themself with the data. After carefully reading, codes were developed so that similar codes would be grouped into categories. Deductive and inductive type analysis was employed to establish codes known as a priority and newly emerged from the data. Similar codes are grouped into categories. Data were summarized from each code and categorized into themes, and then interpreting and writing the data was done. To support our analysis Open Code software Version 4.03 was used to code and categorize qualitative data. Findings from pregnant women and health workers were triangulated. This helps to the validity of the data and shows conflicting views. Emerged themes were supplement-related barriers, pregnancy and experience-related barriers, facility-related barriers, perceived family support, and perceived cultural belief. Finally, the results of the qualitative study were triangulated with the quantitative results.

Result

Socio-demographic and economic characteristics of respondents

In this study, a total of 378 participated with a response rate of 98.94%. The mean age of study participants was 27.14years with SD ± 5.06 and ranging from 15 to 49 years. Of study participants, 311 (83.2%) were between the ages of 20 and 34 and 332(88.88%) live in rural residence. About 143(38.3%) pregnant women were attended high school and above education (Table 1).

Table 1.

Socio demographic and economic characteristics of pregnant mothers attending ANC in Anlemo Woreda, Southern Ethiopia, 2021.

Variable	Category	Frequency	%
Age of women	15-19years	14	3.7
	20–34 years	311	83.2
	35–49	49	13.1
Marital Status	Married	370	98.9
	Others*	4	1.1
Religion	Protestant	196	52.4
	Muslim	156	41.7
	others**	22	5.9
Occupational status	Merchant	52	13.9
	Housewife	281	75.1
	Others***	41	11
Family income in Ethiopian birr	<=1500	52	13.9
	1500–3000	123	32.9
	> 3000	199	53.2
Residence	Urban	42	11.2
	Rural	332	88.8
Educational status	No formal education	142	38.0
	Primary level(1–8)	89	23.8
	High school (9–12)and above	143	38.2
Family size	≤ 4	176	47.1
	> 4	198	52.9

*Others: (single, divorced and widowed) **others: (Orthodox and Catholic) ***others: (employed, Student and Farmers.

IFA related variables

Among 374 study participants, 55(14.7%) respondents reported disliking the taste of IFA, and 9 (2.4%) fear of baby size increase were reasons for missing the dose of the tablet, 163 (43.6%) fear of side effects. Out of respondents who reported missing IFA doses due to side effects, 131(73.79%) respondents reported heartburn, 23(13.94%) respondents reported nausea, and 11(6.67%) respondents reported vomiting.

Findings from qualitative in-depth interviews participants express that the reason for the missing of the consuming IFA are fear of side effects like nausea, heartburn, diarrhoea, constipation and vomiting.

“As soon as I took the Iron tablets, I felt nauseous and heartburn. So I stopped taking tablets.” P10, 28-year-old, non-compliant.

Key informant interview study participants witness that pregnant women were not consuming IFA The reasons cited by key informative interview for not consuming IFA by pregnant women were abdominal discomfort, nausea and vomiting.

“…Some pregnant mothers during ANC visits reports that the missing of IFA tablets consumption due to abdominal discomfort, diarrhoea, heart burn tests of iron when they took the tablets.” P17, 25-year-old, midwife.

The qualitative findings revealed that perceived fear of large baby/fetus weight increase perceived cultural beliefs of still outcomes use of iron tablets during pregnancy.

“…I fear of large baby/fetus, weight was 3.75 kg. During last time pregnancy, I gave birth by operation at hospital ‘Cesarean section’due to tablet intake. So I regret to take tablet not to give birth by surgically” P5, 25-year-old, non-compliant.

Behavior related variables

About 133(35.6%) respondents forget to take IFA as prescribed and per scheduled; this was other reasons for not consuming the dose of the tablet as prescribed.

The reason narrated by health workers and pregnant women for consuming IFA tablet was forgetfulness to take on the time and everyday as recommended.

“The other reason pregnant women for the loss of tablets is not only the side effects but also forgetfulness take IFA.’’ P21, 30-year-old, midwife.

“I want to take the iron tablets as advised by health workers. Sometimes I forgot to take the tablet as usual time. I take it ‘IFA tablets’ when I remember in a day even if usual time pass” P9, 29-year-old, Compliant.

Pregnancy and experiences related variables

Among study participants, more than half of the pregnant, 213(57.0%), initiated ANC visits before 16 weeks, and 161(43%) at or after 16 weeks. Regarding previous history of stillbirth or abortion, 20(5.3%) participants had a previous history of stillbirth or abortion, and 354(94.7%) did not. Of the total respondents, 50(13.4%) pregnant women had a history of anemia during pregnancy whereas 324(86.6) did not. In terms gravidity, 344(92%) pregnant women were multigravidas, and 30(8%) was in their prim-gravidity. About 314(84%) study participants were in the third trimester, and 165 (60%) were in the second trimester. Concerning ANC visits, 234(62.6%) study participants had four or more ANC visits whereas 140(37.4%) had fewer than four ANC visits. Regarding their history of previous pregnancy, 144(38.5%) women had four or more previous history of pregnancies while 230(61.5%) women had less than four.

As key informant interviews participants explains ANC early initiated, within 16 weeks of gestation, pregnant women mostly take IFA tablet as prescribed. Those mother visits health facility early for ANC follow has time to get education, support, and counseling from health care worker on their concern about IFA and other health issue. Pregnant woman has time took the recommended dose 90 plus IFA.

“If pregnant mothers come to our health facility at an early week’s pregnancy, we get enough time for counseling IFA side effects and it management, its importance, and to follow pregnant women about IFA consumption status. They “Pregnant women” will get education, support, and counseling on IFA and……. which them to improve IFA consumption status.” P17, 27-year-old, midwife.

An in-depth interview participant describes the reason for taking IFA tablets like fear of diseases like anemia and low weighted child. Participants explain that understanding consequence of not taking IFA improve uptake table.

“I have been taking tablet ‘IFA’ for last months because if I don’t take it ‘iron tablet’ daily, it would cause illness ‘anemia’ to me and my fetus.’’ P6, 30-year-old, compliant.

Facility-related variables

The two third of respondents, 248(66.3%), had received counseling on IFA while 126(33. 7%) did not. Due to IFA shortage in the healthy, 21(5.6%) of mothers were stopped taking of IFA and 353(94.4%) were not. Among the respondents, 188 (50.3%) mothers to took less than or equal to 30 min reach the nearest health institution, and 186 (49.7%) mothers took greater than 30 min. The median distance to reach the nearest health institution in minutes for the study participants was 35.

As health workers explained counseling pregnant women of IFA about the side effects and its management strategies, and the importance of IFA for pregnant mothers and fetuses. Also study participants described appropriate the time to take, and the results of not taking IFA will helps pregnant women to take IFA tablets as prescribed. As one health professional note.

“We, healthcare professionals, counsel pregnant mothers about the importance of IFA for pregnant mother and fetus, side effects of IFA like heartburn, when taking (after 30 minutes of consuming coffee, tea.). And we also highlighting not stops taking it ‘IFA tablets’ and describes its consequences like anemia, low birth child………” P16, 27-year-old midwife.

In an in-depth interview, the participant explained the importance of counseling like on IFA consuming importance, side effect and consequence of not taking IFA pregnant women and their fetuses helps initiates consume IFA.

“….I have been consuming tablets ‘Iron folic acid’. Health care provider told that pills ‘Iron folic acid’ prevents me and my fetus from anemia and other disease.” (P1, 26-year-old, Compliant).

Study participants reported that shortage of IFA of happens in health facilities is one challenge. Shortage of one of the reasons for missing recommended doses of IFA.

“… Sometimes IFA tablets are not available in our health center. We cannot supplement with IFA. Pregnant mothers interrupt consumption of pills ‘IFA’.” (P19, 31-year-old, Midwife).

Knowledge of anemia among respondents

From this study, about 202 (54%) of the respondents had good knowledge of anemia, and the remaining 172 (46%) had poor knowledge of anemia (Table 2).

Table 2.

Knowledge of anemia among pregnant women attending ANC in Anlemo Woreda, Southern Ethiopia, 2021 (n = 374).

Variable	Category	Frequency	%
Diversified food intake can prevent anemia	Yes	338	90.4
	No	31	8.3
	I don’t know	5	1.3
Illness can cause anemia	Yes	310	82.9
	No	44	11.8
	I don’t know	20	5.3
Bleeding can cause anemia	Yes	312	83.4
	No	49	13.1
	I don’t know	13	3.5
malaria can cause anemia	Yes	173	46.3
	No	132	35.3
	I don’t know	69	18.4
Worm infestations can cause anemia	Yes	223	59.6
	No	97	25.9
	I don’t know	54	14.4
HIV /AIDS can cause anemia	Yes	231	61.8
	No	82	21.9
	I don’t know	61	16.3
Paleness around gums is a sign of anemia	Yes	182	49.6
	No	117	31.9
	I don’t know	68	18.5
Dizziness is a symptom of anemia	Yes	316	84.5
	No	42	11.2
	I don’t know	16	4.3
General fatigue is a symptom of anemia	Yes	302	80.7
	No	53	14.2
	I don’t know	19	5.1
Anorexia is a sign of anemia	Yes	268	71.7
	No	94	25.1
	I don’t know	12	3.2
Pregnant Women might die due to anemia	Yes	260	69.5
	No	82	21.9
	I don’t know	32	8.6
Pregnant women lose their weight due to anemia	Correct	313	83.7
	Incorrect	50	13.4
	I don’t know	11	2.9
Anemia can cause fetal death during pregnancy	Yes	237	63.3
	No	98	26.2
	I don’t know	39	10.4
Anemia can cause the low birth weight of the baby	Yes	281	75.1
	No	56	13.4
	I don’t know	37	10.1
Anemia during pregnancy can be consequences of a premature baby	Yes	192	51.3
	No	125	33.4
	I don’t know	57	15.2
Anemia during pregnancy can be consequences of stillbirth and abortion	Yes	253	67.6
	No	73	19.5
	I don’t know	48	12.8
Taking iron foliate supplement during pregnancy can treat and prevent anemia	Yes	285	76.2
	No	77	20.6
	I don’t know	12	3.2
Receiving blood can treat anemia	Yes	315	84.2
	No	53	11.2
	I don’t know	6	1.6
Knowledge of anemia	Poor knowledge	172	46
	Good knowledge	202	54

Knowledge of the importance of IFA consumption among respondents

The result of this study shows that about 260 (69.5%) of the respondents had good knowledge and the remaining 114 (30.5%) had poor knowledge of the importance of IFA consumption among pregnant women attending ANC (Table 3).

Table 3.

Knowledge of the importance of IFA consumption among pregnant women attending ANC in Anlemo Woreda, Southern Ethiopia, 2021(n = 374).

Variable	Category	Frequency	%
IFA consumption during pregnancy is important to give birth to a healthy baby	Correct	328	87.7
	Incorrect	30	8.0
	I don’t know	16	4.3
IFA consumption during pregnancy is important to protect pregnant women from anemia	Correct	323	86.4
	Incorrect	45	12.0
	I don’t know	6	1.6
IFA consumption during pregnancy is important to improve general health during pregnancy	Correct	320	85.6
	Incorrect	51	13.6
	I don’t know	3	0.8
IFA deficiency during pregnancy can cause anemia	Correct	294	78.6
	Incorrect	67	17.9
	I don’t know	13	3.5
IFA deficiency during pregnancy can be consequences of maternal morbidity and mortality	Correct	261	69.8
	Incorrect	74	19.8
	I don’t know	39	10.4
IFA deficiency during pregnancy can be a consequence of infant mortality	Correct	218	58.3
	Incorrect	98	26.2
	I don’t know	58	15.5
IFA deficiency during pregnancy can be consequences of low birth weight	Correct	251	67.1
	Incorrect	86	23.0
	I don’t know	37	9.9
IFA deficiency during pregnancy can be consequences of Preterm delivery	Correct	231	61.8
	Incorrect	108	28.9
	I don’t know	35	9.4
Knowledge of the importance of IFA consumption among women	poor knowledge	114	30.5
	good knowledge	260	69.5

Family support

The majority of respondents 357(95.5%) didn’t get family support from husbands and other families pregnancy to consume IFA. However, 17(4.5%) respondents had received family support from husbands and other families on the intake of IFA during pregnancy.

As study cited social support helps to consume IFA pills as recommended. Pregnant women who haven’t got family support from different source mentioned as one of barrier.

“…I forgot to consume tablets ‘IFA’ as prescribed by health workers at night after dinner…… I haven’t got support from my husband or other family. I am busy by doing other duties at home and any one remind me to take tablets ‘IFA’.’’ (P13, 36-year-old, non-compliant).

In-depth interview participants describe having social support from husband or others members helps pregnant women to consume of IFA.

“….I haven’t missed the tablet because my husband reminds me to take it. …………….” (P11, 31-year-old pregnant woman, compliant).

Compliance with IFA consumption

Out of 374 mothers, 249 (66.58%) (95% CI, 61.5-71.4%) of respondents were compliant with IFA supplements (took ≥ 21 tablets per month from the previous month) who were prescribed IFA supplements during the current pregnancy (Fig. 1).

Fig. 1.

Proportions of pregnant women who comply with iron folate supplement in Anlemo woreda, South Ethiopia, 2021.

From a key informant interview participants rationalize educational status of pregnant women is very important influencing factors for pregnant women to consume the IFA tablets appropriately. The in-depth interview participants confirmed not formally educated pregnant mothers were less compliant than from formally educated.

“Educated mothers have a good knowledge to understand health importance and use of on IFA than those pregnant mothers who were not formally educated; formally educated mothers ready to accept the advising of IFA than those not formally educated.” P20, 30-year-old, Nurse)

Factors associated with compliance to IFA Consumption

In binary logistic regression analysis: educational status of mothers, forgetting to take the IFA consumption, fear of baby size increase, fear of side effect, like of the IFA taste, received counseling of IFA, shortage IFA in the health facility, timing of initiation of ANC visit, frequency of ANC visits, knowledge of anemia, and knowledge of importance IFA consumption was significantly associated with compliance to IFA consumption with p.value less than 0.25 at 95% confidence interval and were a candidate variables for multivariable model analysis.

In multivariable logistic regression model analysis: educational status of mothers, counseling on the IFA consumption, knowledge of the importance of IFA consumption, knowledge of anemia, the timing of initiation of ANC visit, frequency of ANC visits, and side effects of IFA were significantly associated with compliance with IFA consumption during pregnancy.

Pregnant mothers whose had completed primary level educational status were 5.15 times more likely to be comply with IFA consumption compared to no formal educated (AOR = 5.15, 95% CI (2.47, 10.74)), and high school and above 3.01 times more likely to be comply with IFA consumption compared to no formal educated (AOR = 3.01, 95% CI (1.43, 6.35). Pregnant mothers who had good knowledge of the importance of IFA consumption were 2.95 times more likely compliant compared to those who had poor knowledge about the importance of IFA consumption (AOR = 2.95, 95% CI (1.45, 6.02). Pregnant mothers who had good knowledge of anemia were 2.63 times more likely compliant compared to those who had poor knowledge (AOR = 2.63, 95% CI (1.29, 5.37). Mothers who were afraid of side effects were 92% reduced odds of compliance of IFA consumption (AOR = 0.08, 95% CI (0.02, 0.24). Mothers who visited ANC for four and more were 2.70 times more likely to be compliant with IFA consumption compared to mothers who visited ANC less than four times(AOR = 2.70, 95% CI (1.17, 6.22). Mothers who registered early gestational age (< 16 weeks) for ANC visits were 4.63 times more likely compliant with the IFA consumption compared to mothers who were registered lately (> 16 weeks) (AOR = 4.63, 95% CI = (1.50, 14.26). In this study, pregnant mothers who were counseled on IFA consumptions during pregnancy were 3.95 times more likely compliant than those who were not counseled on intake of IFA consumption (AOR = 3.95, 95% CI (1.57, 6.98) (Table 4).

Table 4.

Factor associated with compliance to IFA among women attending ANC at Anlemo Woreda, Southern Ethiopia, 2021(n = 374).

Variables	Compliance to IFA consumption		COR(95% CI)	AOR(95% CI)	P-value
	No	Yes
Educational status of mothers
No formal education	73 (51.4%)	69 (48.6%)	1	1
Primary level(1–8)	25 (28.1%)	64 (71.9%)	2.71(1.54,4.78)	5.15(2.47,10.7)	< 0.001*
High school (9–12)and above	27(18.9%)	116(81.1%)	4.55(2.67,7.74)	3.01(1.43,6.35)	0.004*
Age of mothers
< 25 years	75(38.9%)	118(61.1%)	1	1
>=25 years	50(27.6%)	131(72.4%)	1.67(1.08,2.58)	1.53(0.86,2.72)	0.149
Forget to take the iron-folate consumption
Yes	62(46.6%)	71(53.4%)	0.41(0.26,0.63)	0.72(0.39,1.34)	0.300
No	63(26.1%)	178(73.9%)	1	1
Fear of baby size increase
Yes	7(77.8%)	2(22.2)	0.14(0.28,0.67)	0.14(0.01,1.44)	0.098
No	118(32.3%)	247(67.7)	1	1
Side effect
Yes	44(27.0%)	119(73.0%)	1.69(1.08,2.63)	0.08(0.02,0.24)	< 0.001*
No	81(38.4%)	130(61.6%)	1	1
Like the taste of IFA
Yes	24(23.1%)	80(76.9%)	1.99(1.19,3.35)	1.69(0.85,3.37)	0.135
No	101(37.4%)	169(62.6)	1	1
Received counseling on IFA
Yes	55(21.8%)	197(78.2%)	4.82(3.02, 7.6)	3.95(1.57,6.98)	0.004*
No	70(57.4%)	52(42.6%)	1	1
Shortage IFA in the health facility
Yes	12(57.1%)	9(42.9%)	0.35(0.15,0.86)	0.47(0.15,1.52)	0.207
No	113(32.0%)	240(68.0%)	1	1
Timing of initiation of ANC visit
Early(16 weeks)	44(20.7%)	169(79.3%)	3.89(2.47,6.12)	4.63(1.50,14.26)	0.008*
Late( > = 16 weeks)	81(50.3%)	80(49.7%)	1	1
Frequency of ANC visits
< 4 visits	78(55.7%)	62(44.3%)	1	1
>=4 visits	47(20.1%)	187(79.9%)	4.6(2.91,7.28)	2.70(1.17,6.22)	0.019*
Knowledge of anemia
Poor knowledge	77(51.3%)	73(48.7%)	1	1
Good knowledge	48(21.4%)	176(78.6%)	3.87(2.46,6.08)	2.63(1.29,5.37)	0.008*
Knowledge of IFA consumption
Poor knowledge	65(57.0%)	49(43.0%)	1	1
Good knowledge	60(23.10%)	200(76.90%)	4.42(2.76,7.07)	2.95(1.45,6.02)	0.003*

* = significant at P-value < 0.05after adjusted for other variables, 1 = reference.

Discussion

In this study, the compliance to IFA was 66.58% (95% CI, 61.5-71.4%) among pregnant women and factors associated with compliance to IFAS were included: maternal education, counseling on the IFA consumption, knowledge of the importance of IFA consumption, knowledge of anemia, timing of initiation of ANC visit, frequency of ANC visits, and side effects of IFA. Supplement-related, pregnancy and experience-related, behavioral -related, perceived family support, and perceived cultural belief findings were identified from qualitative study.

The finding is similar to other studies conducted in India¹³, Nigeria¹⁴, Ethiopia²⁵, and Wolait Zone²⁶. The finding of this study is also higher than the study done in Kenya²⁷, Jimma Town¹⁸, southeast Ethiopia¹⁵, Afar²¹, northwest Ethiopia¹⁷, southern Ethiopia²³, Aykel town²⁸, Burji²⁹, Debre Tabor³⁰, Tigray³¹, Hawassa²⁵, Southwest Ethiopia³², and EMDHS 2019¹⁹.

The probable reason for inconsistency may be difference measuring compliance level (current study used pill count), differences in geographic locations, socio-demographic and socioeconomic status of the study participants (88.8% of current study participants at were from rural and 75.1% were household wife by occupation), the study time difference, the data collection instrument used, and the difference in the study setting.

In this study, pregnant mothers who were having primary education were 5.2 times and high school and above education were 3 times more likely to comply with IFA than pregnant mothers who were not formally educated. This finding is supported by other studies done in sub-Saharan Africa²², India¹³, southeast¹⁵, northwest Ethiopia¹⁷, Lay Armachiho, Northwest Ethiopia³³, and Burji²⁹. Educated pregnant mother might have access to get health information by reading and advice from different sources about IFA and the dangers of anemia to pregnant mother and their fetus. Educations enhance pregnant mothers’ awareness about IFA importance to prevent anemia. Educated mothers have better skills to understand health care ideas on IFA compliance than those pregnant mothers who were not formally educated. Generally, educated women have a greater ability to stick to health care information^15,20. The possible reasons as expressed by key informant educated pregnant women highly accept and comply to health professionals’ advice about IFA consumption²⁰.

This study showed that pregnant mothers who registered early for ANC visits were 4.6 times more likely to be comply with IFA consumption pregnancy compared to those who were late initiation ANC visits ( > = 16 weeks). This result is consistent with other studies conducted in Northwest¹⁷, Northwest Ethiopia³³, Burji²⁹, Debre Tabor³⁰, and Jimma town¹⁸. The possible reason may be pregnant mothers who registered for early for ANC adequate time for counseling on IFA importance and improved knowledge about anemia and its prevention. It could also be that women who attend ANC earlier are more contacts and motivated to comply to a counseling given than late ANC initiation^34,35.

In this study, pregnant mothers who had visited ANC four and more times were 2.7 times more likely to be compliant with IFA consumption than mothers who visited ANC less than four times. The finding is similar to studies done in Sub-Saharan Africa³⁶, in the Misha district²³, and Dembia district¹⁶.

The possible reason might be more ANC visits increase opportunity for frequent contact and counseling by health workers which will increase awareness on IFA, and change misunderstandings and misconception among pregnant women^20,37,38.

In this study, pregnant mothers who received counseling were 3.95 times more likely to be complying with IFA consumption than those who did not receive counseling. This result is consistent with other studies conducted in Senegal³⁹, rural districts of Ethiopia⁴⁰, southern Ethiopia²³, and southeast Ethiopia¹⁵. Appropriate counseling on IFA reduce fears of the possible side effects they may experience, and helps to understand importance of IFA, side effect and its managements and consequence not consuming IFA on pregnant women and their child which improve compliance to IFA^38,41,42.

In this study, the side effects of IFA were one of the factors that affect the compliance of IFA. Side effects experienced by pregnant mothers were statistically significant and have an independent negative predictor of IFA compliance. Pregnant mothers in this study who were fear of side effects had 92% reduced odds of developing compliance of IFA. The side-effect is repeatedly considered a major compliance problem. In this study, the side effect is 43.6% of the mother as a reason for missing doses of IFA. The result is consistent with studies conducted in Dembia district¹⁶, in Northwest¹⁷, and Hawassa city Ethiopia²⁵. One probable justification may be the lack of clear and appropriate information about the potential side effects of IFA and its management. Not consuming IFA due fear of side effects maybe resulted from getting insufficient and inefficient counseling on side effects and its management, and IFA importance from health care provider⁴². Results from the qualitative part of the study showed that the main reason for missing the IFA consumption among most of the pregnant mothers who participated in an in-depth interview was fear of side effects such as feeling nauseous, vomiting, constipation, and heartburn secondary to taking the supplements^38,41.

In this study, forgetfulness is 53.4% of the mother as a reason for missing one or more doses of iron folate pills. This finding was similar to the study done in Dembia district Ethiopia¹⁶, Misha district, Ethiopia²³, northwest Ethiopia¹⁷, and a systematic review in Ethiopia²⁰. Further, it can be prevented by the support of family members and compliance can be improved by developing the appropriate message and improving communication¹⁷.

Knowledge of anemia was also another predictor in this study; pregnant mothers who had good knowledge of anemia were 2.63 times more likely to be compliant with i IFA consumption during pregnancy compared to those who had poor knowledge. This finding is similar to other studies conducted in Eight rural districts⁴⁰, and southern Ethiopia²³. The probable justification maybe, pregnant women who had good knowledge on IFA had knowledge on importance IFA, knowledge on anemia, side effects and its managements, and consequences of not consuming of IFA^41,43.

Pregnant mothers who had good knowledge of the importance of IFA consumption during pregnancy were 2.95 times more likely to be compliant with IFA consumption during pregnancy compared to those who had poor knowledge of the importance of IFA consumption. This result is similar to the study conducted in Nigeria¹⁴, Northern Ethiopia in Dambiaa district¹⁶, Southeast Ethiopia¹⁵, Burji Districts Southern Ethiopia²⁹, Adwa town Tigray Ethiopia³¹, Misha²³, Debre Tabor General Hospital³⁰, and Hawassa city South Ethiopia²⁵. Findings from the qualitative component also showed that women were encouraged to consume the tablets if they have good knowledge about the tablets, especially the benefits and side effects of the tablets, and knowledge about anemia and the importance of IFA can be increased by giving adequate counseling during medical advice. A qualitative finding of this study reveals that family support and adequate counseling play a great role in improving IFA compliance; therefore they remind mothers to take IFA pills without missing, to tolerate fears of the side effects of IFA pills, and minimize side effects of IFA pills⁴³.

On the other hand, a qualitative result of this study shows that fears of side effects of IFA tablets, forgetfulness, dislike of the taste of IFA tablets, and inadequate IFA tablets main reasons for non-compliance of IFA in pregnant mothers. This similar with study findings Southeast Ethiopia Dembia district¹⁶, Burji District²⁹, Jimma district¹⁸, and Northwest²⁸. The possible explanation might be that health professionals did not appropriately counseling about the benefits, side effects and its management, and how to memorize the time for taking iron folate^16,42.

Strength

Counting pills physically to determine compliance helps reduce recall biases. The implementation of mixed method (qualitative and qualitative method) could be the strong side of this study. Data was collected from 5 different health centers, which enhances the generalizability of the findings.

Conclusions

The compliance rate of IFA consumption of the pregnant mothers was 66.58%. Maternal education, counseling on the IFA consumption, knowledge of the importance of IFA consumption, knowledge of anemia, timing of initiation of ANC visit, frequency of ANC visits, and side effects of IFA were factors affect compliance of IFA. Supplement-related, pregnancy and experience-related, behavioral -related, perceived family support, and perceived cultural belief findings were identified from qualitative study.

Therefore, Compliance of IFA of pregnant mothers can further be increased by improving proper counseling about IFA pills intake and educating mothers about anemia and the importance of the IFA pills.

Also promoting mothers to initiation of ANC visits start before 16 weeks and get ANC services at a minimum of four visits can improve their compliance with iron-folate consumption.

Recommendations

The zonal health department and woreda health office should be strengthen of health services by monitoring and evaluation; should trained health service providers on counseling techniques on compliance of IFA; avail IFA tablets to health facility.

Health care providers should provide properly counseling for pregnant mothers on side effects of IFA and its managements; on anemia and its consequence, the importance of IFA;

Promote early initiation of ANC visit (before 16 weeks) and more than four ANC contacts with health workers.

Abbreviations

ANC

Antenatal Care

AOR

Adjusted Odd Ratio

CI

Confidence Interval

COR

Crude Odd Ratio

EDHS

Ethiopian Demography Health Survey

EMDHS

Ethiopian Mini Demography Health Survey

Hb

Hemoglobin

IFA

Iron and Folic Acid

SPSS

Statistical Package for Social Sciences

WHO

World Health Organization

Author contributions

M A: had contributed a lot to the conception, acquisition of data, analysis, and interpretation of data; WK DH, and LE had revised the paper from proposal development to manuscript preparation. All authors read and approved the final version of the manuscript.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethical approval

Ethical clearance was obtained from Institutional Review Board (IRB) of Wolaita Sodo Universitywas with an approval ID CRCSD/45/01. Accordance with the Declaration of Helsinki, all the study participants were informed about the purpose of the study, their right to refuse or withdraw the interview at any time if they want to discontinue, written and signed voluntary consent was obtained from all study participants prior to the interview. For those mothers whose age is less than 18 years the consent was inquired from her parents/ guardian guided.