Adherence to Iron Supplementation in 22 Sub-Saharan African Countries and Associated Factors among Pregnant Women: A Large Population-Based Study

Prevalence and determinants of breast cancer screening in four sub-Saharan African countries: a population-based study

OBJECTIVES

Breast cancer is the most prevalent cancer and the second leading cause of cancer-related deaths among women after cervical cancer in much of sub-Saharan Africa. This study aims to examine the prevalence and sociodemographic-socioeconomic factors associated with breast cancer screening among women of reproductive age in sub-Saharan Africa.

DESIGN

A weighted population-based cross-sectional study using Demographic and Health Surveys (DHS) data. We used all available data on breast cancer screening from the DHS for four sub-Saharan African countries (Burkina Faso, Ivory Coast, Kenya and Namibia). Breast cancer screening was the outcome of interest for this study. Multivariable Poisson regression was used to identify independent factors associated with breast cancer screening.

SETTING

Four countries participating in the DHS from 2010 to 2014 with data on breast cancer screening.

PARTICIPANTS

Women of reproductive age 15-49 years (N=39 646).

RESULTS

The overall prevalence of breast cancer screening was only 12.9% during the study period, ranging from 5.2% in Ivory Coast to 23.1% in Namibia. Factors associated with breast cancer screening were secondary/higher education with adjusted prevalence ratio (adjusted PR)=2.33 (95% CI: 2.05 to 2.66) compared with no education; older participants, 35-49 years (adjusted PR=1.73, 95% CI : 1.56 to 1.91) compared with younger participants 15-24 years; health insurance coverage (adjusted PR=1.57, 95% CI: 1.47 to 1.68) compared with those with no health insurance and highest socioeconomic status (adjusted PR=1.33, 95% CI : 1.19 to 1.49) compared with lowest socioeconomic status.

CONCLUSION

Despite high breast cancer mortality rates in sub-Saharan Africa, the prevalence of breast cancer screening is substantially low and varies gradually across countries and in relation to factors such as education, age, health insurance coverage and household wealth index level. These results highlight the need for increased efforts to improve the uptake of breast cancer screening in sub-Saharan Africa.

Integrating Calcium Into Antenatal Iron-Folic Acid Supplementation in Ethiopia: Women's Experiences, Perceptions of Acceptability, and Strategies to Support Calcium Supplement Adherence

Recommendations for antenatal calcium supplementation to prevent preeclampsia could substantially reduce maternal mortality, but adherence to multiple daily doses may constrain effectiveness. World Health Organization guidelines recommend 3 daily calcium supplements (1.5-2 g/d), taken separately from 1 iron-folic acid (IFA) supplement; however, limited data suggest lower calcium doses may also be effective. We conducted mixed-methods household trials to identify strategies for supporting adherence and integrating calcium into antenatal IFA supplementation programming in Ethiopia. Participants were randomly assigned to 3 regimens varying in dose and timing and were later given a choice of regimens. Semistructured interviews conducted over 6 weeks explored acceptability, barriers, and facilitators and offered opportunities to choose calcium pill type. Interviews were transcribed, translated, and analyzed thematically. Calcium adherence was measured using medication event monitoring. All participants (N=48) agreed to try supplementation. Adherence barriers included forgetting to take pills when busy or travelling and perceived side effects. Midday doses were the most challenging because of farming, market, and social events; women avoided taking supplements in public due to fear of being perceived as HIV positive. Social support from families, visual reminders, and anticipated benefits motivated adherence. More participants (75%) selected chewable versus conventional supplements due to organoleptic properties, but this preference declined over time. Adherence rates did not substantially differ across regimens with 2 (81.1%), 3 (83.4%), or 4 (77.1%) pill-taking events. Women indicated that the 2-event regimen was more acceptable than 3- and 4-event regimens, but this acceptability was not associated with higher adherence. Consequently, mean daily calcium consumption (811.3 mg) was lower than for 3-event (1,251.1 mg) and 4-event (1,156.4 mg) regimens. Integrating calcium into antenatal IFA supplementation is acceptable to Ethiopian women, with a 3-event regimen yielding the highest consumption rates. Despite women experiencing challenges with midday dosing and stigma, using simple home-based strategies and being counseled on the purpose of supplementation were more effective than reducing dosage for mitigating barriers and improving adherence.

Associations of malaria, HIV, and coinfection, with anemia in pregnancy in sub-Saharan Africa: a population-based cross-sectional study

BACKGROUND

Malaria and HIV are common infections in Africa and cause substantial morbidity and mortality in pregnant women. We aimed to assess the association of malaria with anemia in pregnant women and to explore the joint effects of malaria and HIV infection on anemia in pregnant women.

METHODS

We used nationally representative, cross-sectional demographic and health surveys (DHS) that were conducted between 2012 and 2017 across 7 countries of sub-Saharan Africa (Burundi, the Democratic Republic of the Congo, Gambia, Ghana, Mali, Senegal and Togo). The outcome variables were anemia (defined as a hemoglobin concentration < 110 g/L), and hemoglobin concentration on a continuous scale, in pregnant women at the time of the interview. We used generalized linear mixed-effects models to account for the nested structure of the data. We adjusted models for individual covariates, with random effects of the primary sampling unit nested within a country.

RESULTS

A total of 947 pregnant women, ages, 15-49 y, were analyzed. Prevalence of malaria only, HIV only, and malaria- HIV coinfection in pregnant women was 31% (95% CI: 28.5 to 34.5%, n = 293), 1.3% (95% CI: 0.77 to 2.4%, n = 13) and 0.52% (95% CI: 0.02 to 1.3%, n = 5) respectively. Overall prevalence of anemia was 48.3% (95% CI: 45.1 to 51.5%). The anemia prevalence in pregnant women with malaria infection only was 56.0% (95% CI: 50.1 to 61.7%); HIV infection only, 62.5% (95% CI: 25.9 to 89.8%); malaria- HIV coinfection, 60.0 (95% CI: 17.0-92.7%) and without either infection, 44.6% (95% CI: 40.7 to 48.6%). In the fully adjusted models, malaria infection was associated with 27% higher prevalence of anemia (95% CI of prevalence ratio: 1.12 to 1.45; p = 0.004), and 3.4 g/L lower hemoglobin concentration (95% CI: - 5.01 to - 1.79; p = 0.03) compared to uninfected pregnant women. The prevalence of HIV infection and malaria-HIV coinfection was too low to allow meaningful analysis of their association with anemia or hemoglobin concentration.

CONCLUSION

Malaria was associated with an increased prevalence of anemia during pregnancy.

Factors Associated with Urinary Iodine Concentration among Women of Reproductive Age, 20-49 Years Old, in Tanzania: A Population-Based Cross-Sectional Study

BACKGROUND

Universal salt iodization (USI) is the most feasible and cost-effective, and equitable, approach to prevent iodine deficiency. Severe maternal iodine deficiency during pregnancy is associated with serious adverse gestational and birth outcomes.

OBJECTIVES

The aim was to assess iodine status and identify independent factors associated with urinary iodine concentration (UIC) among women of reproductive age in Tanzania.

METHODS

This was a weighted, population-based, cross-sectional study in 2985 women of reproductive age (20-49 y) in Tanzania who participated in the Demographic and Health Surveys in 2015-2016 (DHS 2015-2016) and had measured UIC. Multivariable generalized linear regression was used to identify potential factors that were associated with UIC.

RESULTS

The median UICs among women consuming inadequately iodized salt (93.6 μg/L; 25th and 75th percentiles: 43.1, 197.9 μg/L) and women in the lowest socioeconomic status (92.3 μg/L; 45.6, 194.4 μg/L) were below the WHO-recommended ranges (≥150 μg/L for pregnant women and ≥100 μg/L for nonpregnant women). The results of multivariable models indicated that pregnant women had 1.21 μg/L lower UIC than nonpregnant women (β = -1.21; 95% CI: -3.42, -0.12), breastfeeding women had 1.02 μg/L lower UIC than nonbreastfeeding women (β = -1.02; 95% CI: -2.25, -0.27), and women with no education had a 1.88 μg/L lower UIC compared with those with secondary/highest education (β = -1.88; 95% CI: -4.58, -0.36). Women consuming inadequately iodized salt had 6.55 μg/L lower UIC than those consuming adequately iodized salt (β = -6.55; 95% CI: -9.24, -4.33). The median UIC varied substantially across geographic zones, ranging from 83.2 μg/L (45.9, 165.3) in the Western region to 347.8 μg/L (185.0, 479.8) in the Eastern region.

CONCLUSIONS

Our findings indicated a great heterogeneity in median UIC across regions of Tanzania among women of reproductive age. Poverty, consuming inadequately iodized salt, and lack of education appeared to be the driving factors for lower UIC in Tanzania.