Iron supplementation during pregnancy in Sweden: to what extent is the national recommendation followed?

Non-invasive hemoglobin screening device: a promising digital method for reducing anemia prevalence through routine screening and timely intervention

BACKGROUND

Several non-invasive technologies are nowadays available in the market which claim to determine the hemoglobin levels instantly without the requirement of the blood sample. But no study has shown the significance of such non-invasive devices on a routine basis for determining their impact on anemia reduction programs. This study is conducted to determine the impact of regular hemoglobin screening on the women population to determine its potential in reducing anemia, using a digitalized non-invasive device.

METHOD

A cross-sectional study was conducted on 203 women of reproductive age group, residing in the Moradabad district. Repetitive readings were taken after a time interval of a minimum of 1 month for determining the impact of regular screening. The entire data collection process was carried out using the EzeCheck mobile app.

RESULTS

It was observed that the prevalence of anemia was reduced upon the second time screening and was accepted by the women population. Repetitive testing has a significant impact on reducing anemia prevalence. Also, the simplified non-invasive technology for estimating the hemoglobin values, makes the user more comfortable to take the test.

CONCLUSION

Non-invasive devices should be used regularly to keep track of hemoglobin levels which will help in the effective treatment of anemia. The mobile app-based testing could help to easily evaluate the reports of the patients from any remote location with instant result interpretation and health assistance.

The Experience of Anaemia and Ingesting Oral Iron Supplementation in Pregnancy: A Qualitative Study

INTRODUCTION

The objective of this study was to understand the experience of iron deficiency anaemia requiring oral iron in pregnancy and the factors affecting compliance with oral iron supplementation. Participants' understanding regarding the possible consequences of anaemia in pregnancy was also explored. Feedback on a proposed randomised controlled trial of daily versus alternate day oral iron in pregnancy was sought.

MATERIALS & METHODS

Following ethical approval, fourteen semi-structured one-to-one interviews were carried out using an interview tool with open-ended questions. Recruitment was carried out through social media and from an antenatal out-patient setting. Interviews were audio-recorded, transcribed and analysed thematically.

RESULTS

Fatigue emerged as a predominant and troubling symptom. Awareness was often highlighted through friends/family and from healthcare professionals, particularly in first pregnancies. Knowledge surrounding the potential short-term and long-term adverse consequences of untreated anaemia however was limited. Gastro-intestinal side-effects, a previous experience of poor tolerance and forgetfulness all negatively impacted compliance with oral iron supplementation in pregnancy. Routine, a perceived improvement in fatigue with supplementation and reduced dose frequency recurred as themes which positively affected compliance. Pregnancy as a motivating factor recurred as a theme in analysis. The role of diet was felt to be important. Knowledge of iron-rich foods and absorption aids and inhibitors was good, but practice on optimal ingestion of oral iron supplementation varied. Feedback on trial acceptability was positive with the benefit of extra supportive care noted. Incorporating study visits with routine care was advised in view of time constraints. This area of research was perceived as important.

CONCLUSION

In order to successfully reduce the rates of iron deficiency anaemia in pregnancy, it is crucial that all factors affecting compliance with oral iron are considered. Providing women with the important information on the possible consequences of sub optimally treated anaemia may help to improve this public health issue.

Utilization and compliance with iron supplementation and predictors among pregnant women in Southeast Ethiopia

Anemia is predicted to affect 38% (32 million) of pregnant women worldwide. However, evidence for utilization and compliance with iron supplementation and predictors during pregnancy in low-income countries, including Ethiopia, is sparse and inconclusive. Therefore, we aimed to assess utilization and compliance with iron supplementation and predictors among pregnant women in Robe Town, Southeast Ethiopia. A community-based cross-sectional study was employed among randomly selected 445 pregnant women attending antenatal care at health facilities from May to July 2015. A systematic random sampling was used to select respondents. Data were collected using a pre-tested, interviewer-administered, structured questionnaire. Bivariable and multivariable logistic regression analyses were conducted to identify predictors of compliance with iron supplementation. An odds ratio, along with a 95% confidence interval (CI), was used to estimate the strength of the association. In this study, 54% [95% CI (49.4, 58.4%)], 45.2% [95% CI (40.9, 49.4%)], 4.3% [95% CI (2.5, 6.3%)], and 2.2% [95% CI (1.1, 3.6%)] of women received iron supplements during their first, second, third, and fourth antenatal care visits, respectively. The level of compliance with iron supplementation was 92.4% [95% CI (89.9, 94.6%)]. Having a formal education (AOR = 4.45, 95% CI 1.41, 13.99), being in the high wealth quintile (AOR = 0.18, 95% CI 0.05, 0.68), medium wealth quintile [(AOR = 0.33, 95% CI (0.11, 0.98)], receiving iron supplements for free (AOR = 3.77, 95% CI 1.33, 10.69), not experiencing discomfort related to iron supplements intake (AOR = 2.94, 95% CI 1.17, 7.39), having comprehensive knowledge about anemia (AOR = 2.62, 95% CI 1.02, 6.70), being knowledgeable about iron supplements (AOR = 3.30, 95% CI 1.12, 9.76), having information about importance of iron supplementation during pregnancy (AOR = 2.86; 95% CI 1.04, 7.87), and ever being visited by urban health extension workers (AOR = 0.31; 95% CI 0.12, 0.83) was significantly associated with compliance with iron supplementation during pregnancy. The utilization of iron supplementation during pregnancy was low, with relatively high compliance with the supplements. Thus, comprehensive nutrition education and free provision of iron supplementation are crucial tools to increase utilization and compliance with iron supplementation during pregnancy. Further research with a strong study design using golden standard methods is warranted.

Barriers and facilitators of micronutrient supplementation among non-pregnant women of reproductive age in Johannesburg, South Africa

The prevalence of anaemia among South African women of reproductive age (WRA) remains high at 39%. Multiple micronutrient supplementation (MMS) may be an effective strategy in the prevention and management of anaemia. Our aim was to understand facilitators and barriers to preconception MMS adherence and to explore perceptions and beliefs of MMS in the prevention and treatment of anaemia among non-pregnant WRA. This qualitative study was embedded in a preconception MMS intervention trial of WRA and was conducted in two phases. Phase one assessed the barriers and facilitators of MMS adherence. Individual interviews were conducted with the community health workers (n = 7) administering MMS, and with non-pregnant WRA (n = 25) participating in the trial. Phase two included four focus groups with participating WRA (n = 26), which further explored participants' perceptions and beliefs of MMS provision and adherence, and strategies to improve adherence. The reported facilitators to supplementation were family support, interaction with the community health workers, easy access to MMS, and experienced benefits of MMS. Barriers to preconception supplementation included the lack of family support, the link of supplements to antenatal care, and the perceived lack of benefits of MMS. Participants reported negative associations of supplements with medication, individual and societal stigma around medication and challenges around the supplementation schedule. For successful preconception MMS interventions, young women, their families, and communities need to be convinced of the value of supplementation. Public health interventions utilising preconception supplementation will require specialised training for health care providers, targeted counselling materials and community household support.

Perinatal outcomes of women with hypertensive disorders of pregnancy in Jimma Medical Center, southwest Ethiopia: Retrospective cohort study

BACKGROUND

Hypertensive disorders of pregnancy (HDP) increases adverse perinatal outcomes in women with the disorder. About 16% of all still births and 10% of early neonatal deaths are accounted by HDP. In Ethiopia, HDP complicates about 6% of all pregnancies. Hence, the objective of this study was to determine the risk of adverse perinatal outcomes among women with HDP in Jimma Medical Center, southwest Ethiopia.

METHODS

A retrospective cohort study was conducted on a total of 777 women who gave birth from June 2017 to March 2020 at Jimma Medical Center, southwest Ethiopia. Women with HDP and normotensive women who gave birth at or after 28 weeks of gestation were enrolled as exposed and unexposed respectively. Simple random sampling technique was used to select study participants. Data were reviewed using structured data collection performa that was prepared after reviewing relevant literatures. Data were entered to Epi-Data then exported to STATA version 13 for analysis. The adverse perinatal outcomes risk were examined using log binomial and modified Poisson regression model with robust standard errors.

RESULTS

In this study, the overall incidence of adverse perinatal outcome was higher among women with hypertensive disorders of pregnancy (HDP) than normotensive women (64.1% versus 32.8%). After adjusting for confounders, women with HDP were at higher risk of babies with low birth weight (adjusted RR = 2.88 (2.2, 3.75)), preterm birth(aRR = 2.31(1.7, 3.14)), fifth minute low Apgar score (aRR = 2.6(1.53, 4.42)), admission to neonatal intensive care unit (aRR = 1.77(1.32, 2.37), stillbirth (aRR = 2.02(1.11, 3.01)), and perinatal mortality (aRR = 3.88(1.97, 7.66)) than normotensive women.

CONCLUSION

Women with hypertensive disorder of pregnancy were at higher risk of adverse perinatal outcomes than normotensive women who gave birth at Jimma Medical Center, southwest Ethiopia. Therefore, health care providers should strengthen prevention, early diagnosis and prompt management of HDP in order to reduce adverse perinatal outcomes.

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

BACKGROUND

Iron deficiency anemia during pregnancy is a significant public health problem in sub-Saharan Africa (SSA) and is associated with serious adverse health outcomes. Although it is recommended that all women receive iron supplementation during pregnancy, little research has been conducted to measure overall compliance with this recommendation or variation across SSA countries.

OBJECTIVES

To assess prevalence and sociodemographic-economic factors associated with adherence to iron supplementation among pregnant women in SSA.

METHODS

This was a weighted population-based cross-sectional study of 148,528 pregnant women aged 15-49 y in 22 SSA countries that participated in the Demographic and Health Surveys (DHS) in 2013-2018 and measured iron supplementation during pregnancy. Adherence to iron supplementation was defined as using iron supplementation for ≥90 d during pregnancy of the most recent birth.

RESULTS

The overall prevalence of adherence to ≥90 d of iron supplementation during pregnancy was 28.7%, ranging from 1.4% in Burundi to 73.0% in Senegal. Factors associated with adherence included receiving ≥4 antenatal care visits [adjusted Prevalence Ratio (aPR): 25.73; 95% CI: 22.36, 29.60] compared with no antenatal visits; secondary or higher education (aPR: 1.17; 95% CI: 1.14, 1.19) compared with no education; wealthy (aPR: 1.13; 95% CI: 1.10, 1.16) compared with poor; and older women aged 35-49 y (aPR: 1.07; 95% CI: 1.05, 1.10) compared with younger women aged 15-24 y.

CONCLUSIONS

Adherence to iron supplementation during pregnancy in SSA is low and varies substantially across countries and in relation to factors such as number of antenatal visits, education, and level of family wealth. These results underscore the need for increased efforts to improve the uptake of iron supplementation for pregnant women in SSA.

High Adherence to Iron/Folic Acid Supplementation during Pregnancy Time among Antenatal and Postnatal Care Attendant Mothers in Governmental Health Centers in Akaki Kality Sub City, Addis Ababa, Ethiopia: Hierarchical Negative Binomial Poisson Regression

Background

Iron deficiency during pregnancy is a risk factor for anemia, preterm delivery, and low birth weight. Iron/Folic Acid supplementation with optimal adherence can effectively prevent anemia in pregnancy. However, studies that address this area of adherence are very limited. Therefore, the current study was conducted to assess the adherence and to identify factors associated with a number of Iron/Folic Acid uptake during pregnancy time among mothers attending antenatal and postnatal care follow up in Akaki kality sub city.

Methods

Institutional based cross-sectional study was conducted on a sample of 557 pregnant women attending antenatal and postnatal care service. Systematic random sampling was used to select study subjects. The mothers were interviewed and the collected data was cleaned and entered into Epi Info 3.5.1 and analyzed by R version 3.2.0. Hierarchical Negative Binomial Poisson Regression Model was fitted to identify the factors associated with a number of Iron/Folic Acid uptake. Adjusted Incidence rate ratio (IRR) with 95% confidence interval (CI) was computed to assess the strength and significance of the association.

Result

More than 90% of the mothers were supplemented with at least one Iron/Folic Acid supplement from pill per week during their pregnancy time. Sixty percent of the mothers adhered (took four or more tablets per week) (95%CI, 56%—64.1%). Higher IRR of Iron/Folic Acid supplementation was observed among women: who received health education; which were privately employed; who achieved secondary education; and who believed that Iron/Folic Acid supplements increase blood, whereas mothers who reported a side effect, who were from families with relatively better monthly income, and who took the supplement when sick were more likely to adhere.

Conclusion

Adherence to Iron/Folic Acid supplement during their pregnancy time among mothers attending antenatal and postnatal care was found to be high. Activities that would address the above mentioned factors were highly recommended to ensure the sustainability of mothers’ adherence to the supplement.

Factors associated with non-adherence to prescribed iron supplement use: a study with pregnant women in the city of Rio de Janeiro

Abstract Objectives: to identify factors associated with non-use of iron supplements (IS) by pregnant women attending National Health System (SUS) prenatal care in the Municipality of Rio de Janeiro. Methods: a cross-sectional study was conducted in 2007/2008 with a representative sample of pregnant women using SUS hospitals and basic care in the Municipality of Rio de Janeiro. The group that had gestational age of ≥ 20 weeks at the time of the interview and who had been prescribed IS (n=1407) was subjected to a Poisson multiple regression model to estimate the association between use and independent variables. Results: of the 1407 pregnant women, 65% reported use of IS. Younger age, black skin/race, larger number of births, not having received guidance on use of IS, not having tried to obtain IS at the SUS (with a stronger association between pregnant women with lower levels of education and lower household assets indicator - HAI) and not having been able to obtain them at the SUS (amongpregnant women with lower HAI) were significantly associated with non-use. Conclusions: the guidance of health professionals regarding use of IS and their regular availability may increase adherence to prescription among pregnant women and prevent iron deficiency anemia.

Compliance with Iron-Folate Supplement and Associated Factors among Antenatal Care Attendant Mothers in Misha District, South Ethiopia: Community Based Cross-Sectional Study

Background. In Ethiopia, higher proportions of pregnant women are anemic. Despite the efforts to reduce iron deficiency anemia during pregnancy, only few women took an iron supplement as recommended. Thus, this study aimed to assess compliance with iron-folate supplement and associated factors among antenatal care attendant mothers in Misha district, South Ethiopia. Method. Community based cross-sectional study supported with in-depth interview was conducted from March 1 to March 30, 2015. The sample size was determined using single population proportion to 303. Simple random sampling technique was used to select the study participants. Bivariate and multivariable logistic regression analyses were employed to identify factors associated with compliance to iron-folate supplement. Results. The compliance rate was found to be 39.2%. Mothers knowledge of anemia (AOR = 4.451, 95% CI = (2.027,9.777)), knowledge of iron-folate supplement (AOR = 3.509, 95% CI = (1.442,8.537)), and counseling on iron-folate supplement (AOR = 4.093, 95% CI = (2.002,8.368)) were significantly associated with compliance to iron-folate supplement. Conclusions. Compliance rate of iron-folate supplementation during pregnancy remains very low. This study showed that providing women with clear instructions about iron-folate tablet intake and educating them on the health benefits of the iron-folate tablets can increase compliance with iron-folate supplementation.

Nutrition advice during pregnancy: do women receive it and can health professionals provide it?

A healthy diet during pregnancy is essential for normal growth and development of the foetus. Pregnant women may obtain nutrition information from a number of sources but evidence regarding the adequacy and extent of this information is sparse. A systematic literature review was conducted to identify sources of nutrition information accessed by pregnant women, their perceived needs for nutrition education, the perceptions of healthcare providers about nutrition education in pregnancy, and to assess the effectiveness of public health programs that aim to improve nutritional practices. The Scopus data base was searched during January, 2013 and in February 2014 to access both qualitative and quantitative studies published between 2002 and 2014 which focused on healthy pregnant women and their healthcare providers in developed countries. Articles were excluded if they focused on the needs of women with medical conditions, including obesity, gestational diabetes or malnutrition. Of 506 articles identified by the search terms, 25 articles were deemed to be eligible for inclusion. Generally, women were not receiving adequate nutrition education during pregnancy. Although healthcare practitioners perceived nutrition education to be important, barriers to providing education to clients included lack of time, lack of resources and lack of relevant training. Further well designed studies are needed to identify the most effective nutrition education strategies to improve nutrition knowledge and dietary behaviours for women during antenatal care.

Perceptions of antenatal iron-folic acid supplements in urban and rural Pakistan: a qualitative study

Background

In Pakistan, 51% of women are anaemic in pregnancy yet only 44% of women use antenatal iron-folic acid (IFA) supplements. Little information exits on the perception and barriers to the use of IFA supplements during pregnancy in Pakistan. The aim of the study was to understand women and healthcare providers’ perceptions, and to investigate the cultural and behavioural factors influencing the use of antenatal IFA supplements in rural and urban settings of Pakistan.

Methods

We conducted 10 focus group discussions with mothers, 10 in-depth interviews with currently pregnant women, 6 in-depth interviews with Lady Health Workers and 4 in-depth interviews with doctors providing antenatal care services. The study was conducted in two districts of Pakistan - district Swabi and Islamabad for rural and urban samples, respectively. Data was collected between August and November 2012.

Results

The majority of women were aware of the perceived benefits of antenatal IFA supplements. However, the rural women had more limited information about the benefits of IFA supplements than the urban women. The facilitating factors for the women’s use of supplements were: they had knowledge of benefits; they had trust in the healthcare providers; the supplements were available; they had the financial capacity to buy them; they felt better after taking these supplements; and they received support from family members. The barriers to the women’s use of supplements were: they forgot to take them; the non-availability of supplements; their limited financial capacity to buy them; the lack of antenatal care services; family members not allowing use of the supplements; not knowing about the benefits or no education; fear or experience of side effects; considering them as contraceptives; and felt better thus stopped.

Conclusion

The coverage of antenatal IFA supplementation can be improved by reducing the barriers related to the use of antenatal IFA supplementation in Pakistan. Interventions focused on providing adequate awareness, good quality counselling, reminder messages, availability of free supplements throughout pregnancy and reducing the side effects should be developed and implemented.

Factors associated with non-use of antenatal iron and folic acid supplements among Pakistani women: a cross sectional household survey

Background

World Health Organization recommends a standard daily oral dose of iron and folic acid (IFA) supplements throughout pregnancy to begin as early as possible. The aim of the present study was to determine the prevalence of use of antenatal IFA supplements, and the socio-demographic factors associated with the non-use of antenatal IFA supplements from 14 selected districts in Pakistan.

Methods

Data was derived from a cross sectional household survey conducted in 14 project districts across Pakistan. Trained female field workers conducted interviews with married women of reproductive age from December 2011 to March 2012. Women with the most recent live births in the preceding five years of the survey were selected for this study. Data was analysed by using STATA 13 and adjusted for the cluster sampling design. Multivariate logistic regression models were constructed to identify the independent factors associated with the non-use of antenatal IFA supplements.

Results

Of 6,266 women interviewed, 2,400 (38.3%, 95% CI, 36.6%, 40.1%) reported taking IFA supplements during their last pregnancy. Among IFA users, the most common source of supplements was doctors (49.4%) followed by community health workers (40.3%). The mean (±SE) number of supplements used was 76.9 (±51.6), and the mean (±SE) month of pregnancy at initiation of supplementation was 5.3 (±1.7) months. Socio-demographic factors significantly associated with the non-use of antenatal IFA supplements were living in Dera Ghazi Khan district (AdjOR: 1.72), maternal age 45 years and above (AdjOR: 1.97), no maternal education (AdjOR: 2.36), no paternal education (AdjOR: 1.58), belonging to the lowest household wealth index quartile (AdjOR: 1.47), and no use of antenatal care (ANC) services (AdjOR: 13.39).

Conclusions

The coverage of antenatal IFA supplements is very low in the surveyed districts of Pakistan, and the lack of parental education, older aged women, belonging to poorest households, residence in Dera Ghazi Khan district and no use of ANC services were all significantly associated with non-use of these supplements. These findings highlight the urgent need to develop interventions targeting all pregnant women by improving ANC coverage to increase the use of antenatal IFA supplements in Pakistan.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2393-14-305) contains supplementary material, which is available to authorized users.

Coverage, compliance and factors associated with utilization of iron supplementation during pregnancy in eight rural districts of Ethiopia: a cross-sectional study

Background

Despite the efforts to reduce iron deficiency during pregnancy, information on the coverage and factors associated with utilization of iron supplements is lacking. The study is intended to assess the coverage, compliance and factors associated with the use of prenatal iron supplements in eight rural districts of Ethiopia.

Methods

The study comprised two independent surveys conducted among pregnant women (n = 414) and women who gave birth in the preceding year of the survey (n = 1573). In both cases, respondents were selected using multistage sampling technique and data were collected via structured questionnaire. Predictors of iron supplement utilization (ranked categories of number of prenatal supplements taken) were identified using ordinal logistic regression. The outputs of the analysis are given using adjusted Odds Ratio (OR) with 95% Confidence Interval (CI).

Results

Among women who gave birth in the preceding year, 35.4% (95% CI: 31.3-39.5) were given/prescribed prenatal iron supplement during the index pregnancy and only 3.5% were supplemented for the recommended 91 or more days. Compared to women who had 4 or more ANC visits, those with 0, 1, 2 and 3 visits had 0.04, 0.33, 0.50 and 0.60 times less odds of iron supplement utilization, respectively. Women lacking comprehensive knowledge of anemia (OR = 0. 75 (95% CI: 0.57-0.97)) and those who weren’t informed about the importance of iron supplementation during the pregnancy (OR = 0. 05 (95% CI: 0.04-0.07)) had significantly lower utilization. On the other hand, in pregnant women the prevalence of anemia was 33.2%. Among pregnant women who were given/prescribed supplements, the average level of compliance was 74.9% and about 25.1% had less than 70% adherence. The leading reported reasons for non-adherence were side-effects (63.3%) and forgetfulness (16.7%).

Conclusion

Promoting early and frequent ANC, enhancing the quality of ANC counseling and promoting the knowledge of women on anemia are essential strategies for improving the utilization of iron supplements.

Iron supplementation among pregnant women: results from a population-based survey study

Objectives: To measure the prevalence and risk factors associated with iron supplementation among pregnant women in the municipality of Rio Grande, Southern Brazil. Methods: All mothers living in this municipality who had children in 2007 were surveyed for demographic, socioeconomic and health care received during pregnancy and childbirth. The statistical analysis consisted of Poisson regression with robust adjustment of variance, and the measure of effect was prevalence ratio (PR). Results: Among the 2,557 mothers interviewed (99% of total), 59% were supplemented with iron during pregnancy period. After adjusting for various confounding factors, a higher PR to iron supplementation was observed among teenagers, women with black skin color, primigravidae, who had six or more antenatal visits, who performed prenatal care in public sector and received vitamin during pregnancy. Conclusion: There is a clear need to increase the iron supplementation coverage of all pregnant women, especially among those currently considered with low gestational risk.

Effect of multiple micronutrient supplementation on pregnancy and infant outcomes: a systematic review

Supplementation with multiple micronutrients (MM) during pregnancy may result in improved pregnancy and infant outcomes. We conducted meta-analyses of randomised controlled trials that evaluated the effects of prenatal supplementation with MM (defined as containing at least five micronutrients and typically included iron or iron and folic acid). The outcomes of interest were low birthweight (<2500 g), birthweight, small-for-gestational age (SGA), gestational age, preterm birth (<37 weeks' gestation), stillbirth and neonatal death, maternal morbidity and mortality. We identified eligible studies through PubMed and EMBASE database searches. Meta-analyses were performed by pooling results for outcomes that were reported from more than one trial and sub-analyses were conducted to evaluate the effect of timing of intervention and amount of iron. We included published results from 16 trials in this review. Compared with control supplementation that was usually iron plus folic acid in most studies, MM supplementation resulted in a significant reduction in the incidence of low birthweight [pooled risk ratio (RR) 0.86; 95% confidence interval (CI) 0.81, 0.91] and SGA (pooled RR 0.83 [95% CI 0.73, 0.95]) and an increase in mean birthweight (weighted mean difference (WMD) 52.6 g [95% CI 43.2 g, 62.0 g]). There was no significant difference in the overall risk of preterm birth, stillbirth, and maternal or neonatal mortality, but we found an increased risk of neonatal death for the MM group compared with iron-folate in the subgroup of five trials that began the intervention after the first trimester (RR 1.38 [95% CI 1.05, 1.81]). None of the studies evaluated maternal morbidity. Compared with iron plus folic acid supplementation alone, prenatal maternal supplementation with MM resulted in a reduction in the incidence of low birthweight and SGA but increased risk of neonatal death in the subgroup of studies that began the intervention after the first trimester.

Social determinants of iron supplementation among women of reproductive age: a systematic review of qualitative data

Iron supplementation for women of reproductive age is a main part of an interdisciplinary strategy recommended for the control and prevention of iron deficiency and the treatment of mild-to-moderate iron-deficiency anaemia. This systematic review reports the findings from a meta-synthesis of qualitative data concerning the experiences and perceptions of iron supplementation among women of reproductive age and health service providers worldwide. Qualitative systematic review methods were used to conduct a search of published literature, define inclusion and exclusion criteria, appraise quality of studies and extract data on the use of iron supplementation among women of reproductive age. Coding, thematic analysis, reciprocal translation and line of argument synthesis were used to synthesize data. Twelve studies spanning 17 countries met inclusion criteria and were included in the analysis. Seven domains emerged from the review: cultural norms and societal values including explanatory models and medical pluralism; political and socio-economic circumstances; education and communication; social organization and social relationships; health care access and supplement supply; food and nutrition availability; and adherence. In addition, 16 sub-domains are highlighted. Connecting review findings to a conceptual framework of social determinants of health highlights salient issues that policy makers must consider when adapting global iron supplementation recommendations to the local context.

A comparative evaluation of multiple micronutrient and iron-folic acid supplementation during pregnancy in Pakistan: impact on pregnancy outcomes

BACKGROUND

Maternal micronutrient deficiencies are widespread in Pakistan and are potentially associated with maternal undernutrition and intrauterine growth retardation. Intervention strategies largely consist of administration of iron-folic acid supplements during pregnancy.

OBJECTIVE

We evaluated the acceptability of multiple micronutrient supplementation and its potential benefits on pregnancy outcomes and maternal micronutrient status in a cohort of pregnant women in rural and urban Sindh through a cluster-randomized design.

METHODS

We randomly assigned 2378 pregnant women to receive either iron-folic acid or multiple micronutrient supplements. The supplements were administered fortnightly by community health workers who performed home visits to assess tolerance and observe the mothers.

RESULTS

The women in both groups consumed about 75% of the supplements provided, and few reported adverse effects such as vomiting, abdominal pain, etc. There was a small (70 g) but significant increase in birthweight among infants of mothers receiving multiple micronutrients as compared with infants of mothers receiving iron-folic acid supplements (2.95 +/- 0.6 vs. 2.88 +/- 0.5 kg, p = .01). This translated into a 10% reduction (p < 0.17) in the proportion of low-birthweight infants among infants of mothers receiving multiple micronutrients. Although stillbirth rates were comparable in the two groups, the early neonatal mortality rate in the group receiving multiple micronutrients was higher, although not significantly, than that in the group receiving iron-folic acid (43.2 vs. 23.5 deaths per 1000 live births; RR = 1.64; 95% CI, 0.94 to 2.87). Comparable reductions in anemia (hemoglobin < 11 g/dL) were observed, although the proportion with low iron stores (assessed by serum ferritin) was lower in the iron-folic acid group in the postnatal period. Although the proportion of women with subclinical vitamin A deficiency after supplementation did not differ between the two groups, the iron-folic acid group had a higher proportion with lower serum zinc levels in the immediate postpartum period.

CONCLUSIONS

These data suggest that multiple micronutrient supplements are well tolerated during pregnancy, but the effect on birthweight is modest. The observed effect on early neonatal mortality suggests the need for further studies and careful assessment of the intervention in health system settings.

Compliance to iron supplementation during pregnancy

Iron deficiency anaemia is the most common nutritional disorder in the world. Pregnant women are at especially high risk of iron deficiency and anaemia because of significantly increased iron requirements during pregnancy. Iron supplementation during pregnancy has been recommended for women in the developing world, since usually no basic changes occur in the composition of the diet. This is a retrospective cohort study carried out in Al-Yamamah Hospital, Riyadh, Saudi Arabia, comparing the outcome of haemoglobin levels in 308 pregnant women near term with compliance to iron supplementation during the preceding pregnancy stages. Data were collected using an interview-based questionnaire for assessment of supplementation compliance and the women were divided into three categories: strictly compliant; partially compliant; and non-compliant. Haemoglobin levels were extracted from the medical records for the first antenatal visit (before 13 weeks' gestation) and compared with the level at entrance to the study at 36 weeks' gestation. Both Epi-info 2002 version 3.2 and SPSS version 10 were used for data analysis. Our results show that 49.7% used iron supplements continuously during the second and third trimesters of pregnancy; 38.3% reported partial use and 12.0% used no iron supplements. Haemoglobin levels improved significantly only among strictly compliant pregnant women, by 0.3 g/dl; decreased among partially compliant women by, 0.36 g/dl and significantly decreased among non-compliant, by -1.4 g/dl. Factors associated with non-compliance were education with a simple linear protective effect from being non-compliant. The percentage of anaemic women increased from 29.6% in the first trimester to 34% in the third trimester. Anaemia was significantly associated with non-compliance with iron supplementation, the adjusted OR was 6.19 95% CI 2.55-15.02, p < 0.0001. Strategies to improve compliance and effective iron supplementation among pregnant women should be implemented.

Iron supplement use among Danish pregnant women

OBJECTIVES

To evaluate compliance with the national recommendation on supplemental iron to all pregnant women in Denmark and to explore differences between compliers and non-compliers with respect to dietary habits and other lifestyle factors.

DESIGN

Intake of supplemental iron from pure iron supplements and from multivitamin and mineral preparations was estimated in mid-pregnancy.

SETTING

Nationwide cohort study, the Danish National Birth Cohort (DNBC), comprising more than 100,000 women recruited in early pregnancy.

SUBJECTS

Information on diet and dietary supplements was available for 54,371 women. Of these, information on lifestyle factors was available for 50,902 women.

RESULTS

A high compliance with the recommendation was found, as approximately 77% of the women reported use of iron supplements during pregnancy. However, many of the compliers did not obtain the recommended doses of iron, which can partly be explained by the lack of iron preparations of appropriate doses available on the Danish market. Compliance with the recommendation was associated with age above 20 years, primiparity, body mass index<30 kg m- 2, non-smoking and long education. No major differences were seen in dietary intake between compliers and non-compliers.ConclusionOverall, a high compliance rate was found among participants of the DNBC but a clarification on daily dose is needed, and more concern should be paid to vulnerable groups such as young, smoking women and women with no or short education.

Awareness of and compliance with recommended dietary supplement among age-related macular degeneration patients

BACKGROUND

The age-related eye disease study suggested that taking zinc and anti-oxidants supplements could reduce the progression of age-related macular degeneration (AMD). In Australia, the available supplement is Macu-Vision. The study aimed to assess the awareness of and compliance with taking this supplement and the public health implication.

METHODS

The fundus photograph database of patients aged 55 years and older at the ophthalmology department of a public teaching hospital in Adelaide, Australia was reviewed. In total, 125 patients with category 3 and 4 AMD were identified. A total of 100 patients participated in this cross-sectional study.

RESULTS

In total, 53% of participants were aware of the availability of the formulae available in Australia, 38% were taking the supplement and only 1% were taking the correct dose. Of those taking the supplement 95% (36/38) were taking half the recommended dosage. Among those who were aware of the supplement but not taking it, cost was the most common reason (31%). Another 31% were not taking it because of actual side-effects experienced, fear of potential side-effect and/or fear of interaction with other medications. There was no predictive factor for failing to take the formulae available in Australia among age, sex, smoking status, living arrangement and category of AMD.

CONCLUSIONS

Clinicians need to emphasize that the recommended dosage is twice that on the supplement label. If the trend demonstrated here of underutilizing the formulae available in Australia among public hospital patients continues, it is unlikely to have any major public health impact in similar settings in Australia.

Guidelines on anaemia: effect on primary-care midwives in The Netherlands

OBJECTIVE

To assess the adherence and perceived barriers for implementation of a clinical-practice guideline on anaemia, which was the first national guideline for primary-care midwifery in The Netherlands.

DESIGN

Cross-sectional survey study.

SETTING

Primary-care midwifery in The Netherlands.

PARTICIPANTS

160 midwives (60% response rate).

MEASUREMENTS

Questionnaire on the knowledge of, and attitudes and self-reported adherence to, 14 key recommendations in the guideline; attitudes to guidelines in general; and perceived barriers to implementation.

FINDINGS

The number of midwives agreeing with and adhering to specific recommendations varied between 29 and 90%. Most midwives had a positive attitude to the guidelines. The most relevant general barriers were related to the behaviour of general practitioners and obstetricians (32% of the midwives reported this). Larger numbers of midwives mentioned barriers to specific aspects of the guideline, particularly alternative iron supplementation or dietary supplements (59%), and not prescribing iron supplementation if haemoglobin was low but mean corpuscular volume was normal (49%).

KEY CONCLUSIONS

The guideline on anaemia was well received by primary-care midwives in The Netherlands, but implementation of specific recommendations needs further attention.

IMPLICATIONS FOR PRACTICE

The study provides evidence for the national organisation of midwives to continue with the development and implementation of clinical guidelines.

Effects of separate delivery of zinc or zinc and vitamin A on hemoglobin response, growth, and diarrhea in young Peruvian children receiving iron therapy for anemia

INTRODUCTION

Anemia is the most prevalent nutritional deficiency in the world. Attempts to improve iron indexes are affected by deficiency of and interaction between other micronutrients.

OBJECTIVE

Our goal was to assess whether zinc added to iron treatment alone or with vitamin A improves iron indexes and affects diarrheal episodes.

DESIGN

This was a randomized, placebo-controlled, double-blind trial conducted in Peru. Anemic children aged 6-35 mo were assigned to 3 treatment groups: ferrous sulfate (FS; n = 104), ferrous sulfate and zinc sulfate (FSZn; n = 109), and ferrous sulfate, zinc sulfate, and vitamin A (FSZnA; n = 110). Vitamin A or its placebo was supplied only once; iron and zinc were provided under supervision >/=1 h apart 6 d/wk for 18 wk.

RESULTS

The prevalence of anemia was 42.97%. The increase in hemoglobin in the FS group (19.5 g/L) was significantly less than that in the other 2 groups (24.0 and 23.8 g/L in the FSZn and FSZnA groups, respectively). The increase in serum ferritin in the FS group (24.5 mug/L) was significantly less than that in the other 2 groups (33.0 and 30.8 mug/L in the FSZn and FSZnA groups, respectively). The median duration of diarrhea and the mean number of stools per day was significantly higher in the FS group than in other 2 groups (P < 0.005).

CONCLUSION

Adding zinc to iron treatment increases hemoglobin response, improves iron indexes, and has positive effects on diarrhea. No additional effect of vitamin A was found.