Non-adherence to iron and folic acid consumption among Indian pregnant women: evidences from national family health survey-5 data (2019-21)

Abstract

Background

Iron and Folic Acid (IFA) supplementation is one of the highly recommended strategies to tackle anemia. Under the backdrop of high anemia prevalence among pregnant women, this study examines the level of non-adherence with IFA supplementation, separately for 100 + days and 180 + days, among pregnant women in India.

Methods

The analysis is conducted on a sample of 174,947 women, who bought or received IFA tablets/syrup during their last pregnancy, and was surveyed during the National Family Health Survey-5 (2019-21). The NFHS is a cross-sectional survey that claims to represent 95% of the Indian population. The survey adopted stratified random sampling specific to rural and urban population. Descriptive statistics and conditional probabilities are calculated to examine the initiation and attainment of different levels of IFA consumption across selected background variables. Binary logistic regressions are employed to understand the influence of socio-economic factors on non-adherence of IFA supplementation for minimum 100 days and 180 days, and the results are presented as adjusted odds ratios at 95% confidence intervals.

Results

While the probability of initiation of IFA tablets is fairly high among pregnant women in India, the probability of consuming at least 100 tablets declines drastically for pregnant women irrespective of their socio-economic profile. The chances of not taking IFA for at least 100 days and 180 days are lesser by 21% and 15% respectively for urban with respect to rural women. When compared to the richest, the poorest face 1.6 times higher odds for not consuming IFA for at least 100 days, and 1.96 times higher in case of non-adherence for minimum 180 days. Women with no education shows 1.73 and 1.46 times higher likelihood to be non-adherent with both criteria as compared to those with higher education. Minimum four antenatal care (ANC) visits and husband’s presence during any of these visits demonstrated significant associations. Risk of non-compliance is lesser among women with lower birth order as compared to pregnancies of third and higher birth order.

Conclusion

It is mandatory to involve community health workers in awareness generation and close monitoring of IFA consumption behaviour first ensuring access to IFA supplements, and then adherence for 100 + days, which in turn will improve the possibility of meeting 180 days’ recommendation.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12884-026-09639-4.

Introduction

The deficiency of folic acid can cause numerous maternal and foetal health conditions such as spontaneous abortion, megaloblastic anemia in foetus, pre-eclampsia, abruption of placenta, adverse birth outcomes and neural tube defects [1]. In order to address anemia and to improve maternal and foetal health, World Health Organization (WHO) recommends IFA supplementation for all pregnant women, at least for 90 days, regardless of gestation period [2, 3]. The IFA supplementation is one of several important tools or measures to control anemia [4].

The prevalence of anemia among pregnant women has been a critical concern for the health of expectant mothers in Indian society; an issue that continues to persist despite concerted efforts. The pan-India large-scale National Family Health Survey (NFHS)-5 (2019-21) data shows that 57% of women in India are anemic (with almost 32% women being moderately to severely anemic), when compared to 53% in NFHS-4 (2015-16) [5]. The pervasiveness of anemia is 93% in Ladakh (a remote north Indian state bordering China), whereas the prevalence is reported to be more than 60% in union territories and states such as Jammu & Kashmir (neighboring state of Ladakh) and Chandigarh from North India, Dadra & Nagar Haveli and Daman & Diu, and Gujarat from western India, and Chhattisgarh, Bihar, Odisha, Jharkhand, Assam, Tripura, and West Bengal from central and eastern India [5]. Most of these states, especially the ones from central and eastern India are socio-demographically backward, demonstrating poor maternal and child health status. Union territories like Ladakh, Dadra & Nagar Haveli and Daman & Diu are remote tiny geographies. Half of the pregnant women were also found to be anemic during NFHS-5. The Government of India has launched its flagship programme named Anemia Mukt Bharat in 2018 as part of intensified National Iron Plus Initiative (NIPI), aiming to reduce the prevalence rate of anemia at a rate of 3% points per annum. Under this programme, daily one Iron and Folic Acid tablet is recommended to be consumed starting from the fourth month of pregnancy for a period of minimum 180 days during pregnancy and to be carried on for another 180 days during post-partum period. Earlier according to the National Health Mission guideline for antenatal care, a pregnant lady has to be given one tablet of IFA (100 mg elemental iron and 0.5 mg folic acid) every day for a minimum of 100 days after the first trimester within pregnancy [6]. Hence, to ensure success for such programs it is important to study the pattern and likelihood of attaining these important milestones.

Earlier studies have adopted different approaches while measuring the compliance or adherence rate for IFA supplementation among pregnant women, based on number of missed doses, number of days of IFA consumption, or percentage of women missing out on recommended doses/days. Yet, studies from various low- and middle-income countries trying to assess the magnitude of non- adherence, its socio-economic distribution and reasons, have observed that the adherence to IFA supplementation has remained sub-optimal [3, 7, 8]. A systematic review conducted among pregnant women in Sub-Saharan Africa shows an extremely low prevalence of compliance to IFA supplementation [9]. A cross-sectional study conducted in the eastern Terai of Nepal found that IFA compliance rate was 58% during pregnancy and 42% of the respondents were anemic; while the likelihood of being anemic was 24 times more among IFA non-adherent women during pregnancy than their counterparts [8].

In India, a number of previous research show varied rate of IFA compliance. Even though the NFHS-5 (2019-21) survey report states that more than 85% of women who delivered a child during the last five years from the survey were given or bought IFA tablets during their pregnancy, only 44% of all pregnant women took supplementation for at least 100 days [5]. However, a cross-sectional study conducted in a district of west Indian state of Gujarat reported that nearly three-fourth of the surveyed pregnant women were anemic and only 60% of the pregnant respondents received IFA tablets [10]. A study conducted among pregnant women in urban areas of South India (Karnataka) observed that 58.1% of its respondents consumed all the IFA tablets provided to them [11], while studies conducted in Kolkata and Delhi observed that women attending ANC services were better compliant to the IFA supplementation [12, 13]. However, a study conducted in a smaller city found that only 52.5% were compliant to IFA supplementation [14]. A number of factors can be attributed to inadequate consumption of IFA supplementation. Multiple studies evaluating factors influencing IFA supplementation in smaller research settings found that several socio-economic and demographic indicators along with knowledge of IFA supplementation, number of antenatal care visits, birth order, play important roles in adherence to IFA supplementation in India [11, 15, 16]. However, there has been variations in the way these parameters impact the IFA consumption pattern. Since, previous studies conducted in India showed that anemia was more prevalent among those pregnant women who were non-compliant to recommended IFA doses [13, 14], this is important that more efforts are made to understand the IFA consumption pattern in a country where prevalence of anemia among pregnant women has remained alarmingly high.

The review can state that even if studies have examined the IFA supplement consumption pattern and held the non-adherence a one of the responsible factor for anemia among pregnant women, there has been limited efforts to understand the transition from procurement to initiation of consumption, and thereafter reaching important consumption landmarks. Hence, from the program implementation point of view, it is important to monitor and evaluate the adherence status of IFA consumption in any country where there is high prevalence of anemia among women, especially among pregnant women. The present study attempts to assess the level of non-adherence to IFA supplementation for at least 100 days and 180 days of consumption among pregnant women aged 15–49 years in India. The specific objectives are: (1) to study the socio-economic and geographic distribution of non- adherence with the consumption of IFA supplementation for at least 100 days and at least 180 days, (2) to estimate the probability that a woman will start consuming IFA tablets given they have already procured them, and that of continuing for a minimum of 100 days after their beginning of IFA tablets consumption, and finally the probability to reach the milestone of 180 + days once she has consumed for 100 days, and (3) to examine how different socio-economic and demographic covariates are associated with a woman’s propensity to fail to consume IFA tablets/syrup for at least 100 and at least 180 days.

Methods

The data for the analysis are obtained from the “Children’s Recode” (IAKR file) of National Family Health Survey (NFHS)-5 conducted during 2019-21. The NFHS is a cross-sectional study, conducted on a regular interval across all states of India. NFHS-5 collects data on several socio-demographic and public health parameters at both individual and household level, claiming to cover a representative sample of more than 95% of the Indian population. The overall response rate was 97% among women. During the survey, women who have given birth in the last five years were interviewed to understand the percentage of women who were given or who purchased IFA tablets during the pregnancy for their recent birth. From a sample of 664,972 selected households, 747,176 eligible women are identified for individual interviews. This analysis covers only those reproductive age women who bought or received IFA tablets or syrup during pregnancy. Given the fact that a good share of pregnant women bought or received IFA supplements, the rationale behind selecting them as the base population is to examine the consumption behaviour of pregnant women after they have got the access to the supplements. The question that was asked during NFHS survey was, ‘During this pregnancy (during last five years preceding the survey), were you given or did you buy any iron folic acid tablets or syrup?’. The number of tablets were self-reported by the respondents. Out of a total of 230,870 cases, the sociodemographic variables were obtained for a sample size of 174,947 women, with 55,923 missing cases. While the caste variable had 64,468 missing cases, ANC visit and husband related variables had 58,168 and 204,252 missing cases respectively.

The data collection for NFHS-5 was conducted in two phases; first phase was conducted from 17th June 2019 to 30th January 2020 and the second phase spanned between 2nd January 2020 to 30th April 2021). The NFHS-5 provides data for 707 districts, 28 states and 8 union territories following same sample design that were adopted for previous rounds. Each district was stratified in rural and urban areas. Rural areas are further sub-stratified based on the village population size and the percentage of scheduled castes (SC) and scheduled tribes (ST) population, and sorted considering literacy rate among 6 + years old women. In urban areas, census enumeration blocks (CEBs) were selected based on proportion of SC/ST population. Villages and CEBs were considered to be the primary sampling units (PSUs), and were selected with probability proportional to size (PPS) systematic sampling. Consideration of the above-stated background factors and PPS methodology during data collection in tandem with high representativeness of Indian population supposedly eliminated potential bias. To ensure data quality several comprehensive manuals were prepared and followed, and a standard set of 44 field-check tables were referred throughout the data collection. The final sample size is estimated by multiplying the number of PSUs selected and the number of households or women in each PSU. For NFHS-5, a total of 30,456 PSUs were selected [5].

The first part of analyses consists of descriptive analysis to understand the percentage distribution of women complying to consumption of 100 and 180 IFA tablets across various socio- economic characteristics. The second part entails computation of probabilities of (i) IFA initiation, (ii) IFA continuation till 100 + tablets and (iii) continuation from 100 + to 180 + IFA tablets for the sampled women with different background characteristics. The third and final part of the analysis involves logistic regression methods to investigate how different socio-economic and demographic covariates influence a woman’s propensity to fail to consume 100 IFA tablets and 180 IFA tablets. We have additionally conducted two separate bi-variate Pearson correlation analyses to examine the degrees of association of the anemia prevalence with non- adherence to IFA supplementation for 100 + and 180 + days, across thirty-six state and union territories.

For the second part of analyses, the probabilities are calculated as follows:

Let, T: number of IFA tablets consumed by a woman from a particular socio − economic background

n: total sample size.

n(T = t): number of women consuming t number of tablets.

P(T=t): Probability of a woman consuming t number of tablets

Then,

• (i) P(consuming at least one IFA tablet) is given by:

• (ii) P(consuming at least 100 IFA tablet) is given by:

• (iii) P(consuming at least one IFA tablet|the woman procured or bought IFA tablets) is given by:

• (iv) P(consuming at least 100 IFA tablets | the woman procured or bought IFA tablets)

• (v)P(consuming at least100 IFA tablets | the woman initiated IFA consumption)

• (vi)P(consuming at least 180 IFA tablets | the woman consumed at least 100 tablets)

Pairwise Z-tests have been carried out to test whether the conditional probabilities P2s (and P3s) significantly differ from P2s (and P3s) across categories of the selected background variables. For variables with two categories, simple Z-test for two proportions has been used. For variables with multiple categories, pairwise Z-test with Bonferroni correction has been used.

Z-test for two proportions:

Number of pairwise comparisons k: number of categories of the variable.

Adjusted significance level with Bonferroni correction:

For the third part of analyses, two separate binary logit regression are run, delineated as follows:

Model-1.

Dependent variable:

Y = 1: if a woman fails to consume at least 100 IFA tablets; (Y = 0, otherwise)

Model-2.

Dependent variable:

Y = 1: if a woman fails to consume at least 180 IFA tablets; (Y = 0, otherwise)

The general form of binary logit regression model is given by:

where,the ratio is called the odds ratio

the odds ratio implies the likelihood of ocurrence of Y=1 as compared to Y=0

X₁ X₂,....,X_k are the independent variables

β₁,β₂,….,β_k are the changes in the log-natural of odds ratios given as:

Alternatively,e^βi is the change in the odds ratios,given as:

The results are presented as adjusted odds ratios, significant at 95% confidence interval. The list of independent variables for both the models includes place of residence (‘rural’ reference category) [13, 14, 16], age grouped into five categories (’40–49’ reference category) [14, 16], wealth index (‘richest’ reference category) [13, 14, 16], highest education level of women (‘higher’ reference category) [13, 14, 16], caste groups (‘none of them’ reference category) [14, 15, 17], religion (‘Hindu’ reference category) [14–17], four or more antenatal care visits (‘yes’ reference category) [13, 16], partner’s education level (‘higher’ reference category) [8], working status of women (‘no’ reference category) [14, 16, 17], husband or partner’s presence during any ANC visits (even if for only one visit) referring to the last birth (‘yes’ reference category) [17], and birth order of child (‘three and above’ reference category) [16, 17].

Household level wealth index (wealth quintile) is estimated based on scores derived by conducting a principal component analysis using household level data on the quantity and kinds of consumer goods they own, that include various types of furniture, electronic goods, means of transport, and housing characteristics like source of drinking water, toilet facilities, and types of flooring materials. In India, the caste groups are officially classified in four racially distinct categories; Scheduled Castes (SC), Scheduled Tribes, Other Backward Castes (OBCs), and the General (‘none of them’ in this study) category. Scheduled Caste refers to hereditary and hierarchical groups that have historically experienced socio-economic discrimination, Scheduled Tribes are ethnic indigenous communities which have faced social, economic and geographic marginalisation. Full ANC is defined as at least antenatal visits, one or more tetanus toxoid (TT) injection and consumption of iron folic acid (IFA) tablets/syrup for at least of 100 days.

Results

Non-adherence pattern of IFA tablets among Indian women

Here non-adherence to IFA tablets is measured as whether a woman actually consumes the tablets for minimum of 100 days and 180 days after receiving/purchasing them. The state-wise figures clearly portray a geographic pattern. In 2019-21, there are more than 60% of women in northern and eastern states named Uttar Pradesh, Bihar, Jharkhand and Ladakh along with a few remote north-eastern states such as Arunachal Pradesh, Nagaland, Tripura (Fig. 1), who received IFA tablets/syrup but did not consume for more than 100 days. The non-adherence percentage further increases in case of consumption of IFA supplementation for at least 180 days, with Rajasthan accounting for more than 80% non-compliance (Fig. 2). Non-adherence for 100 IFA tablets is lesser than 20% in the southern states of India, including, Kerala, Tamil Nadu and Goa (Fig. 1). The same set of states has been performing better as compared to the rest of the country with respect to non-adherence for minimum 180 days, portraying a non-adherence percentage of less than 40% (Fig. 2).

Fig. 1.

State-wise distribution of percentage of pregnant women not consuming IFA supplementation for at least 100 days

Fig. 2.

State-wise distribution of percentage of pregnant women not consuming IFA supplementation for at least 180 days

Table 1 presents the non-adherence in terms of consumption of IFA for at least 100 days and for at least 180 days by women’s socio-economic and demographic characteristics. It is observed that 45.6% of rural women do not consume IFA tablets for 100 days, even after receiving or buying the tablets/syrup. At the same time, 63.1% of rural women do not consume IFA tablets for 180 days. The non-adherence even after receiving IFA tablets significantly decreases with rise in age, improvement in wealth status, and increase in educational attainment of the respondents and their husbands, for both the categories (100 days’ consumption and 180 days’ consumption). Similar to the pattern observed with other socio-economic indicators, higher percentage of women from underprivileged racial groups such as scheduled caste or scheduled tribe lagged in IFA supplement consumption. The religious disparity has also been noteworthy. More than 40% of Hindus and Muslims demonstrate non-adherence to 100 days of IFA consumption, while the figures surge by another 20% points in case of 180 days’ reference period. Christian women and women belonging to other religions show much better consumption rate. Those who have more than four ANC visits happen to demonstrate better consumption practices as compared to those who received less than four ANC visits. Even though the gap still remains statistically significant, it reduces considering 180 days’ compliance pattern. The consumption pattern varies marginally based on the working status of the women. NFHS-5 data also finds that husband or partner’s presence during ANC is significantly associated with the lower proportion of IFA non-adherence. The non-adherence to IFA consumption is also found to rise with higher birth order, especially when the birth order is three and above.

Table 1.

Percentage distribution of women showing non-compliance to IFA supplementation for at least 100 days and at least 180 days different background characteristics of women even after receiving/ purchasing IFA tablets/ syrup

Co-variates	Categories	Sample size (n)	Not consuming IFA tablets for 100 + days	Chi-squared Sig	Not consuming IFA tablets for 180 + days	Chi-squared Sig
Type of place of residence	Urban	49,341	34.0%	0.000	53.6%	0.000
	Rural	125,606	45.6%		63.1%
Age (years)	15–19	5450	43.0%	0.000	62.0%	0.000
	20–24	51,169	43.6%		62.1%
	25–29	67,798	42.8%		60.6%
	30–39	47,019	40.5%		58.4%
	40–49	3511	39.3%		56.2%
Wealth index	Poorest	39,839	50.9%	0.000	66.6%	0.000
	Poorer	36,811	47.3%		64.5%
	Middle	34,248	41.8%		60.5%
	Richer	33,650	36.9%		56.5%
	Richest	30,397	31.9%		51.4%
Highest educational level	No education	34,143	50.5%	0.000	64.4%	0.000
	Primary	20,527	46.6%		64.2%
	Secondary	90,071	41.2%		60.2%
	Higher	30,206	33.8%		53.8%
Caste/Tribe	SC	39,628	45.0%	0.000	62.3%	0.000
	ST	17,291	41.8%		61.8%
	OBC	75,232	43.4%		59.9%
	None of them	32,694	38.1%		58.1%
Religion	Hindu	139,207	43.0%	0.000	60.8%	0.000
	Muslim	27,843	42.1%		61.1%
	Christian	3689	28.6%		48.5%
	Others	4208	35.5%		51.9%
ANC Visit four and above	No	70,368	51.9%	0.000	65.3%	0.000
	Yes	102,335	36.0%		57.3%
Working status	No	20,782	41.5%	0.012	60.8%	0.362
	Yes	154,165	42.5%		60.3%
Husband/partner’s education	No education	3666	50.4%	0.000	65.9%	0.000
	Primary	3378	44.2%		62.6%
	Secondary	14,653	40.9%		60.8%
	Higher	4803	36.0%		56.2%
Husband/partner’s presence during ANC	No	22,652	48.3%	0.000	63.2%	0.000
	Yes	141,584	41.5%		60.8%
Birth order	One	59,962	43.5%	0.000	65.3%	0.000
	Two	63,556	46.5%		68.3%
	3+	51,429	59.5%		77.9%
Total		174,947	42.3%		60.4%

Progression and dropouts in IFA consumption

Table 2 presents the following probabilities: (1) the probability of consuming IFA supplementation for at least one day; (2) the probability of consuming IFA supplementation for at least 100 days; (3) the conditional probability of consuming IFA supplementation for at least one day provided they were given/bought iron tablets/syrup; (4) the conditional probability of consuming IFA supplementation for at least 100 days provided they were given/bought iron tablets/syrup; (5) the conditional probability of consuming IFA supplementation for at least 100 days given the woman consumed for at least one day; and (6) the conditional probability of consuming IFA supplementation for at least 180 days given the woman consumed for at least 100 days. The analysis of consuming one IFA supplementation dose may not be useful from treatment or prevention perspectives; but looking through the lens of program implementation, this analysis provides us with an idea about till what extend women are completely aversive towards IFA supplementation, or they are losing motivation to continue to consume for at least 100 days, and thereafter for the recommended 180 + days. The analysis of attaining 100 + days consumption based on three different conditions would clarify the effectiveness of the policy interventions and highlight the socioeconomic groups that are lagging behind and those which may derive most from the strategy.

Table 2.

Probability of Initiation and Conditional Probabilities of Continuation of IFA tablets

Variables	Categories	Col.1	Col.2	Col.3	Col.4	Col.5	Col.6
		P1 (n)	P2 (n: same as Col.1)	P3 (n1)	P4 (n1: same as Col.3)	P5 (n2 = n*P1)	P6 (n3= n2*P5)
Place of residence	Urban	0.864 (49341)	0.540	0.966 (44117)	0.604	0.625	0.637
	Rural	0.835 (125606)	0.402	0.961 (109195)	0.462	0.481	0.566
Age groups	15–19	0.856 (5450)	0.445	0.968 (4821)	0.503	0.520	0.573
	20–24	0.849 (51169)	0.433	0.965 (45007)	0.492	0.510	0.573
	25–29	0.846 (67798)	0.441	0.962 (59657)	0.501	0.520	0.596
	30–39	0.838 (47019)	0.453	0.96 (41033)	0.519	0.541	0.605
	40–49	0.76 (3511)	0.384	0.954 (2795)	0.482	0.505	0.561
Wealth index	Poorest	0.794 (39839)	0.308	0.96 (32931)	0.373	0.388	0.490
	Poorer	0.83 (36811)	0.380	0.961 (31786)	0.440	0.458	0.546
	Middle	0.852 (34248)	0.456	0.963 (30325)	0.515	0.535	0.59
	Richer	0.871 (33650)	0.520	0.965 (30371)	0.576	0.597	0.621
	Richest	0.884 (30397)	0.584	0.963 (27899)	0.636	0.660	0.665
Highest educational level	No education	0.752 (34143)	0.271	0.956 (26856)	0.345	0.361	0.489
	Primary	0.82 (20527)	0.377	0.961 (17515)	0.442	0.459	0.531
	Secondary	0.865 (90071)	0.473	0.965 (80805)	0.528	0.547	0.597
	Higher	0.896 (30206)	0.578	0.962 (28137)	0.621	0.645	0.654
Caste/ tribe	SC	0.837 (39628)	0.411	0.96 (34567)	0.471	0.491	0.578
	ST	0.854 (17291)	0.451	0.967 (15264)	0.511	0.528	0.556
	OBC	0.838 (75232)	0.426	0.962 (65538)	0.489	0.508	0.613
	None of them	0.848 (32694)	0.487	0.962 (28811)	0.553	0.575	0.59
Religion	Hindu	0.847 (139207)	0.439	0.963 (122513)	0.499	0.518	0.593
	Muslim	0.82 (27843)	0.417	0.965 (23669)	0.491	0.508	0.546
	Christian	0.856 (3689)	0.581	0.938 (3368)	0.637	0.679	0.656
	Others	0.856 (4208)	0.522	0.957 (3763)	0.583	0.609	0.684
ANC Visit (4+)	No	0.772 (70368)	0.282	0.952 (57105)	0.347	0.365	0.525
	Yes	0.895 (102335)	0.551	0.972 (94279)	0.598	0.615	0.612
Working status	No	0.635 (20782)	0.339	0.962 (18260)	0.513	0.533	0.573
	Yes	0.64 (154165)	0.333	0.962 (135053)	0.502	0.521	0.593
Husband/partner’s education	No education	0.539 (3666)	0.207	0.962 (2980)	0.369	0.383	0.485
	Primary	0.599 (3378)	0.292	0.968 (2881)	0.472	0.488	0.544
	Secondary	0.66 (14653)	0.362	0.964 (13128)	0.529	0.549	0.581
	Higher	0.719 (4803)	0.441	0.961 (4382)	0.589	0.613	0.623
Husband/ partner’s presence during ANC	No	0.767 (22652)	0.324	0.945 (18895)	0.399	0.423	0.551
	Yes	0.842 (141584)	0.459	0.966 (127550)	0.527	0.545	0.594
Birth order	One	0.581 (59962)	0.335	0.967 (54322)	0.558	0.577	0.614
	Two	0.702 (63556)	0.385	0.963 (56563)	0.528	0.548	0.593
	3+	0.644 (51429)	0.269	0.956 (42428)	0.400	0.418	0.545
Total		0.843 (174947)	0.441	0.962 (153312)	0.503	0.573	0.522

n: Total women sample, irrespective of they were given/bought iron tablets/syrup or not

n₁: Number of women who were given/bought iron tablets/syrup

n₂: Number of women consumed for at least one day

n₃: Number of women consumed for at least 100 days

P1: Probability of consuming IFA supplementation for at least one day

P2: Probability of consuming IFA supplementation for at least 100 days

P3: Conditional Probability of consuming IFA supplementation for at least one day provided they were given/bought iron tablets/syrup

P4: Conditional Probability of consuming IFA supplementation for at least 100 days provided they were given/bought iron tablets/syrup

P5: Conditional Probability of consuming IFA supplementation for at least 100 days given the woman consumed for at least one day

P6: Conditional Probability of consuming IFA supplementation for at least 180 days given the woman consumed for at least 100 days

As observed from Table 2, for each background variable, the likelihood of a woman’s initiation of consumption of IFA tablets is ranging from 0.75 to 0.89, which is considerably lower than intended universal coverage. However, provided a woman has obtained IFA tablets or syrup, the probability of initiating the consumption is almost certain (at least 95%) irrespective of her socioeconomic background. But, the likelihood of continuing to consume IFA tablets for at least 100 days decreases significantly for women across all background variables. Yet, the chance that they will reach the 100 days milestone increases if they have bought or given IFA supplements, and further once they start consuming. High dropout rate in consumption of IFA tablets is observed among rural women, those with no or primary education, women from poorest or poorer wealth index and belonging to scheduled caste social group, and among those who did not attain 4 + ANC visits or with three and above birth order. Even urban residents, women with higher education and stronger economic profile, and those who attended 4 + ANC visits demonstrate considerably low probability of continuing IFA supplementation for up to 100 + days.

One noteworthy finding from Table 2 is that once a woman consumes IFA tablets at least 100 days, her likelihood to continue the consumption to at least 180 days increases for all background variables (except for Christians, it is slightly lower). For example, while the probability to reach consumption of IFA tablets to 100 days mark is only 0.361 for women having no education, the probability for consumption of tablets for 180 + days once they finish consuming tablets for at least 100 days is 0.49. Similar patterns can be observed for poorest women and women with no education. Pairwise Z-tests for proportions (see supplementary document) show statistically significant (5% level) variation across most background-variable categories in both the conditional probability of consuming IFA tablets for 100 + days given the initiation has happened and 180 + days provided they have attained 100 days landmark. Women from richest category, other than SC/ST/OBC, higher education level show significantly higher adherence than their counterparts. Among religious groups, Christian women showcase a higher probability to comply to the IFA targets as compared to women from Hindu and Muslim communities. Women with at least four ANC visits exhibit better initiation (0.895) and continuation to 100 days IFA consumption mark (0.615), their continuation to 180 + days (0.612) is significantly higher than those having less than four ANC visits (0.525).

Factors influencing non-adherence to IFA tablet consumption

The logistic regression presented in Table 3 (n = 20,894) shows that the chance of not taking IFA tablets for at least 100 days and at least 180 days are significantly lesser for urban, Christian and scheduled tribe women, and women with lower birth order. The non-adherence is statistically significantly higher among poorer and lesser educated women, and among those who have either missed minimum four ANC visits or who are not accompanied by their husbands during their ANC visits.

Table 3.

Binary logistic regression on non-compliance with IFA supplementation for at least 100 days and at least 180 days even after receiving or purchasing IFA supplementation

Co-variates	Categories	IFA 100				IFA 180
		Sig.	Exp(β)	95% C.I. for Exp(B)				95% C.I. for Exp(B)
				Lower	Upper	Sig.	Exp(β)	Lower	Upper
Place of residence	Rural	1.00				1.00
	Urban	0.000	0.791	0.735	0.851	0.000	0.852	0.790	0.918
Age	40–49
	15–19	0.052	1.330	0.997	1.775	0.846	1.032	0.750	1.421
	20–24	0.000	1.521	1.205	1.921	0.543	1.085	0.834	1.411
	25–29	0.042	1.267	1.009	1.591	0.404	0.896	0.693	1.159
	30–39	0.185	1.167	0.929	1.466	0.247	0.859	0.664	1.111
Wealth index	Richest	1.00				1.00
	Poorest	0.000	1.607	1.421	1.816	0.000	1.962	1.717	2.243
	Poorer	0.000	1.370	1.225	1.530	0.000	1.605	1.428	1.804
	Middle	0.011	1.144	1.031	1.270	0.000	1.291	1.161	1.434
	Richer	0.675	0.979	0.888	1.080	0.000	1.199	1.089	1.321
Education level	Higher	1.00				1.00
	No education	0.000	1.726	1.520	1.959	0.000	1.457	1.266	1.675
	Primary	0.000	1.521	1.337	1.729	0.000	1.394	1.212	1.604
	Secondary	0.000	1.217	1.110	1.335	0.936	0.996	0.908	1.092
Caste	None of them	1.00				1.00
	Schedule caste	0.952	0.997	0.908	1.095	0.988	0.999	0.905	1.104
	Schedule tribe	0.000	0.785	0.695	0.885	0.000	0.760	0.668	0.864
	OBC	0.019	1.100	1.016	1.192	0.441	0.968	0.891	1.052
Religion	Hindu	1.00				1.00
	Muslim	0.932	1.004	0.917	1.099	0.964	1.002	0.908	1.106
	Christian	0.000	0.585	0.472	0.725	0.000	0.569	0.467	0.693
	Other religion	0.834	0.981	0.816	1.179	0.058	0.836	0.694	1.006
ANC Visits: four and above	Yes	1.00				1.00
	No	0.000	2.254	2.119	2.397	0.000	2.093	1.948	2.248
Education level of partner	Higher	1.00				1.00
	No education	0.150	0.907	0.794	1.036	0.372	1.071	0.921	1.245
	Primary	0.001	1.17	1.091	1.259	0.083	0.889	0.778	1.016
	Secondary	0.001	1.16	1.078	1.243	0.161	0.938	0.858	1.026
Working status	No	1.00				1.00
	Yes	0.004	0.901	0.840	0.967	0.001	0.879	0.815	0.947
Husband/partner’s presence during ANC	Yes	1.00				1.00
	No	0.000	1.352	1.241	1.473	0.000	1.199	1.087	1.322
Birth order	Three and above	1.00				1.00
	One	0.000	0.640	0.585	0.700	0.000	0.670	0.608	0.739
	Two	0.000	0.745	0.688	0.806	0.000	0.758	0.694	0.828

Figure 3 demonstrates the scatter plot between anemia and IFA non-adherence for 100 days in India. The analysis shows a positive correlation (correlation coefficient = 0.320 with p = 0.06) between anemia and IFA non-adherence. The outlying state or union territory in this case is Ladakh (a sparsely populated remote North Indian state bordering China), with more than 90% prevalence of ‘any anemia’ (< 11.0 g/dl) in women. More than 50% women in Ladakh are not consuming IFA tablets for 100 days. Figure 4 exhibits a similar pattern in the case of non-adherence for 180 days. The correlation coefficient is 0.258 (with p = 0.131), representing a weak, yet positive association between state-wise prevalence of anemia and IFA non-adherence for 180 + days across states. As in the previous case, 64% women in Ladakh, a region struggling with an extremely high prevalence of anemia, are not consuming the tablet for 180 days.

Fig. 3.

Scatter plots between state-wise prevalence of anemia and IFA non-with an extremely high prevalence of anemia for at least 100 days

Fig. 4.

Scatter plots between state-wise prevalence of anemia and IFA non-adherence for at least 180 days

Discussion

Under the backdrop of an unwavering anemia prevalence, this study highlights a considerable gap in adherence/compliance to IFA consumption for a minimum of 100 days among Indian pregnant women. The findings of this study clearly highlight the status and likelihood of achieving important milestones related to IFA supplementation that are associated with betterment of maternal health outcomes and aligned with policy measures. The probability of consuming IFA supplementation among pregnant women for at least one day is more than 80%. Even if ensuring the availability of IFA supplementation has almost made it certain that a woman will at least start taking IFA tablets/syrup, the probability of consuming those tablets or syrup for 100 days and above given that they have consumed at least one IFA tablet decreases tremendously. The likelihood that a woman will consume 100 + tablets has remained very low, where a stark difference can be observed between the poorest and richest women, and between those who or whose husband did not have any formal education versus those who have attained ‘higher’ education level. Four and above ANC visits and husband’s presence during any ANC visits can make a substantial difference in this regard. At the same time, if a woman consumes IFA tablets/ syrup at least for 100 days, that individual has a higher likelihood to consume at least 180 tablets irrespective of her socio-economic conditions.

While thriving to achieve a universal attainment of 100 + IFA supplementation, the probability of consuming more than 100 IFA tablets appears to be critically low, while that of 180 + tablets is appalling across all socioeconomic groups. However, there is a prominent regional variation in this regard. Socio-demographically and economically advanced south Indian states are doing better than the states from northern and eastern region, and urban population showing more suboptimality than their rural counterparts. Due to this regional disparity of economic development within India, a strong migration flow can be observed from northern, central and eastern Indian states towards southern region of the country, looking for economic well-being. Literature from India showed that poorer migrants experience significantly lower likelihood to consume IFA for at least 100 days or attain full ANC, as compared to their non-poor or non-migrant counterparts [18]. Wealth index and education profile has been found to be significantly associated with recommended consumption of IFA tablet supplementation. Higher frequency of ANC visits certainly improves the compliance.

Even though the measures of non-compliance/non-adherence are different across studies, there has been divergent observations on the association between socioeconomic status and adherence to IFA supplementation. Our study findings support the observations from a previous study, conducted based on large-scale data from India, which found that the women from highest socioeconomic stratum have significantly higher likelihood for consumption of IFA tablets [17]. On the contrary, Deori et al. (2021), studying ANC service seekers from a public hospital in a sub-urban location, showed sub-optimal consumption among well-off women as compared to women from lower socioeconomic status. Studies from other low- and middle-income countries also contribute to this debate [13]. A study conducted in Philippines observed that rural poor was more compliant as compared to the urban poor women [3].

Similar to earlier studies conducted in India our findings also showed that consumption of IFA improves with age [11, 13]. However, there has been varied results across studies while analysing distribution of non-adherence of IFA across women’s age. While, the findings from the regression analysis of the current study observed a significantly higher likelihood towards non-adherence to at least 100 IFA tablets among women aged 20–29 years, and no significant association between age and consumption of 180 + IFA tablets, Chourasia et al. (2017) showed that women aged 30 years and above has 1.5 times higher chance to consume 90 + IFA tablets as compared to 15-19-year-old respondents [17]. However, a survey conducted in Ethiopia found that women in the higher age group (more than 35 years) showed less adherence when compared to women in the age group between 25 and 29 years [19].

Similar to our findings, earlier studies have also found that education of pregnant women is positively associated with IFA adherence [12, 13, 20]. Chourasia et al. (2017) showed that well educated women are four times likely to adhere to the recommended dose of IFA supplementation [17]. A study shows that women with higher level of education along with knowledge of hemoglobin status and iron pill dose has shown higher compliance to iron pills [21]. Studies from other developing countries also demonstrate a similar pattern [3, 22].

Our results bolster the fact that minimum four ANC visits can significantly improve the figures related to adequate consumption of IFA supplementation. In sub-Saharan Africa it was found that IFA supplementation scenario could be improved by escalating the awareness among women about anemia and IFA supplementation, and more than four antenatal care visits [9]. A study based on urban slums in India found that increase in the number of ANC visits increases the consumption of iron pills [21]. Similar to our observations, other studies also have highlighted that there is a positive significance of the presence of partner during antenatal care visits on women consuming IFA tablets for at least 90 days [17]. Beside higher frequency of prenatal care visits, registering pregnancy during first trimester and being attended by any healthcare provider increases the probability of consuming IFA for at least 100 days [20].

In the high focus states of India, birth order (below 2) and mass media exposure showed a significance to women consuming IFA tablets for at least 90 days [17]. Our study based on NFHS-5 data (2019-21) reports that consumption of IFA supplementation decreases with the rise in birth order. These observation is consistent to the findings of an earlier research by Chourasia et al. (2017) which analysed the data from the third round of NFHS survey conducted in 2005-06 [17]. However, Mithra et al. (2014), examining women coming for ANC at a tertiary health centre in a city in south India, found that missing more than two doses is considerably lower among with lower birth order [11].

Limitations

The approach of this study and its findings are not completely void of limitations. The analysis is based on secondary that applies cross-sectional design. Since this study is based on a cross-sectional dataset, the observed associations between socio-demographic characteristics and IFA adherence cannot establish any temporal or causal relationships. Moreover, the information on gap between receiving and consuming IFA tablets are neither exhaustive nor explicit. A few of the reasons are obtained through literature review, could not be examined given the paucity of data in NFHS dataset. Many indicators related to perceptions about IFA supplementation among women could not be captured in this study. More primary researches understanding the roles of community health workers in social mobilization and motivating women reaching a higher IFA consumption level is required. Furthermore, this macro level study fails to answer why certain small states/union territories like Ladakh, Nagaland and Arunachal Pradesh, and large states named Bihar and Uttar Pradesh demonstrate extremely high non-adherence rate. Detailed studies need to conducted to gain community specific understandings on the factors that her hindering adherence to the recommended IFA supplementation. Moreover, since this study is based on secondary dataset we do not have any control over the recall bias in remembering supplement consumption pattern over a period that may span close to five years ago. Additionally, there is also a possibility that there was an impact of COVID-19 pandemic on the ANC services during the reference period considered for the NFHS-5 survey. The dataset does not reflect on this aspect.

Research and policy implications

The reasons

This study hence highlights need for further investigations to understand the suboptimal adherence of IFA supplementation better. Even though several studies have stated multiple reasons behind inadequate consumption, understanding the causes leading to reach important milestones should be examined for better maternal health outcomes. Some of the most common cited reasons for non-compliance to IFA tablets are forgetfulness [11, 12, 21, 23], women’s tendency to ignore personal health issues, size of the tablets [21], side effects of the tablets [11, 14, 23] etc. The other factors which resulted in a gap in the consumption of IFA tablets were inadequate counselling and distribution of tablets, poor utilization of healthcare services provided by the facilities and the prevalence of misconceptions around consuming medicines during pregnancy [11, 23].

Role of frontline health workers

The reasons such as forgetfulness, size and taste of the tablets, unawareness about the consumption pattern etc. can be mitigated by the proper involvement of the community health workers. Earlier studies conducted in developing countries such as India [24], and Brazil [25] found the primary reason for non-adherence was the gap in the information provided by the healthcare workers. A study conducted on tribal adolescent girls in India observed that several qualitative factors influence the adherence and feasibility of IFA supplementation, that include creating awareness by active involvement of anganwadi workers (a frontline community health worker who are mainly females from local community, recruited by the government, taking care of health and nutrition needs and schemes focusing on 0–6 years old children, pregnant and lactating women), ensuring quality of tablets and its timely supply [26]. A study conducted in Uttar Pradesh noted that even if the women are given 100 pills of IFA supplements by the ASHA (Accredited Social Health Activists) workers for a period of three months, they only visit the villages once or twice per month, except attending emergency cases [27]. Informative posters about taking iron supplements, patient centric therapeutic approaches in case of side-effects, providing calendar based reminders can significantly improve the compliance [28]. Studies on backward districts in Gujarat, observed that the external factors constraining the adherence with IFA supplementation are inaccessibility to healthcare facilities, and the economic cost [10].

Broader maternal health considerations

Not only among expectant mothers, prevalence of anemia has remained high even among post-natal women in India [29]. A study conducted in India found that despite high coverage of IFA supplementation, 57% of pregnant and 61% of postpartum mothers with uncomplicated pregnancy were anemic [30]. Smitha et al. (2024) observed that only one-fifth of post-natal women were compliant with IFA supplementation, while more than half of them consumed IFA tablets during pregnancy [31]. Hence, future studies delving into IFA supplementation, anemia prevalence, and the roles of health systems must include post-natal women also under consideration.

This current study highlights the need for complying to the recommended number of days of supplementation. An understanding on periodic adherence/ non-adherence to IFA supplementation under the backdrop of a stubborn rate of anemia urges the policymakers for closer monitoring and evaluation. A study evaluating Anemia Mukt Bharat concluded that the variations in coverage can be due to state-specific heterogeneity [32]. Hence, uniform health care programs, and especially its implementation, may not be applicable in India, requiring tailor-fit policies and strategies. The same study observed that training and awareness generation programs for state and district level officials were impactful towards expanding service coverage. A systemic approach is required to bring synergies in the ecosystem, involving people, frontline health workers, processes, public and private healthcare providers and the state. Overall, the findings of this study strongly align with the Sustainable Development Goal (SDG)-3, that advocates good health and well-being, while emphasizing universal health coverage (Target 3.8) and better maternal health status (Target 3.1).

Conclusion

Even though the availability of IFA supplementation and the proportion of women initiating with the supplementation have been considerably high among pregnant women in India, the non-adherence with consuming minimum 100 and minimum 180 IFA tablets, even after receiving them is highly prevalent among pregnant women in India. This study has helped to understand the dynamics around the progression of likelihood of consuming IFA supplementation for a desired number of days. Since the initiation of IFA supplementation and the probability that IFA is consumed for at least 100 days improve substantially once pregnant women procure or buy IFA tablets/syrup, it is imperative to ensure that all pregnant women are provided with IFA tablets/syrup. On top of that, once we notice that the possibility of a woman will not discontinue taking IFA supplements before 180 days is higher once they consume IFA for at least 100 days, as compared to the probabilities of reaching earlier milestones, the policymakers should design structured monitoring and evaluation framework to follow-up the consumption pattern targeting each important threshold.

Authors’ contributions

AS: Conceptualization, Methodology, Analysis, Writing- Original draft preparation, Supervision, ValidationMP: Conceptualization, Data curation, Analysis, Writing- Original draft preparationTD: Writing- Reviewing and Editing, Analysis, Validation.

Funding

Open access funding provided by Amrita Vishwa Vidyapeetham. The authors received no financial support for carrying out this research.

Data availability

National Family Health Survey data is publicly available at free of cost, and can be downloaded from the Demographic Health Survey website (https://www.dhsprogram.com/).

Declarations

Ethics approval and consent to participate

The protocol and the content of all the data collection tools for the National Family Health Survey (NFHS)-5, was reviewed and approved by the Institutional Review Board of International Institute for Population Sciences (IIPS) and the ICF Institutional Review Board, alongside the U.S. Centers for Disease Control and Prevention (CDC). During the data collection process the health investigators were trained on informed consent procedures, the informed consent statement was read and the consent that was obtained from all of the participants was informed.

Consent for publication

We confirm that no identifying images or other personal or clinical details of any participant has been used in this study or presented in this manuscript. Hence, obtaining a ‘consent for publication’ from participants is not applicable for this manuscript.

Competing interests

The authors declare no competing interests.