The impact of a planned health educational program on the compliance and knowledge of Jordanian pregnant women with anemia

Digital versus non-digital health interventions to improve iron supplementation in pregnant women: a systematic review and meta-analysis

Objective

To investigate the effects of digital health interventions for improving adherence to oral iron supplementation in pregnant women.

Literature search

Five databases were searched from their inception to October 2023 with no date restrictions.

Study selection

Randomized controlled trials (RCTs) that assessed the effects of digital health interventions on adherence to oral iron supplementation (e.g., tablets and capsules) compared to non-digital health interventions for pregnant women were eligible.

Data synthesis

We calculated standardized mean differences (SMDs) and mean differences (MDs) with 95% confidence intervals (CIs) for continuous variables using the inverse variance method. We calculated odds ratios (OR) with 95%CI for categorical variables using the Mantel-Haenszel model. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. The risk of bias of the included RCTs was assessed using the Cochrane risk of bias tool 2.0.

Results

Ten trials with 1,633 participants were included. Based on 7 trials, digital health interventions can improve objective adherence rate comparing with non-digital health interventions (1,289 participants, OR = 4.07 [2.19, 7.57], p < 0.001, I2 = 69%) in pregnant women. Digital health interventions can improve subjective adherence behavior comparing with non-digital health interventions (3 trials, 434 participants, SMD = 0.82 [0.62, 1.01], p < 0.001, I2 = 0%) in pregnant women. Based on 3 trials, digital health interventions can improve tablets consumption comparing with non-digital health interventions (333 participants, SMD = 1.00 [0.57, 1.42], p < 0.001, I2 = 66%) in pregnant women. Digital health interventions can improve hemoglobin level comparing with non-digital health interventions (7 trials, 1,216 participants, MD = 0.59 [0.31, 0.88], p < 0.001, I2 = 93%) in pregnant women.

Conclusion

Digital health interventions were effective at improving adherence to oral iron supplementation and hemoglobin levels in pregnant women.

Effectiveness of nutrition counseling for pregnant women in low- and middle-income countries to improve maternal and infant behavioral, nutritional, and health outcomes: A systematic review

Background

Nutritional counseling, which includes two-way interactive education, has been hypothesized to improve the health and nutritional status of pregnant women, but little is known about the impact such practice of care might have on maternal and infant health and behavioral outcomes of pregnant women living in low income, low-middle income, and upper-middle-income countries (LMIC)s.

Objectives

We conducted a systematic review to appraise the effectiveness and impact on health equity of two-way nutritional counseling practices in LMICs on maternal and infant behavioral, nutritional, and health outcomes.

Search Methods

We conducted electronic searches for relevant studies on Medline, Embase, CINAHL, PsychInfo, and the Cochrane CENTRAL for randomized and non-randomized trials on the effectiveness of two-way interactive nutritional counseling among pregnant women from the date of database inception up to June 22, 2021. In addition, we searched references of included studies in systematic reviews, gray literature resources, and unpublished studies or reports that satisfied our eligibility criteria using a focused Google search.

Selection Criteria

We included randomized and non-randomized controlled studies (NRS), controlled before and after, and interrupted time series that assessed the effectiveness of two-way interactive nutrition counseling targeting pregnant women in LMICs.

Data Collection and Analysis

Data extraction and risk of bias were conducted in duplicate. The risk of bias (ROB) for randomized trials (RCT) was assessed according to the Cochrane Handbook of Systematic Reviews, and ROB for NRS was assessed using the Newcastle-Ottawa scale (NOS). RCT and NRS were meta-analyzed separately.

Main Results

Our search identified 6418 records and 52 studies met our inclusion criteria, but only 28 were used in the quantitative analysis. Twenty-eight studies were conducted in Asia, the most in Iran. Eight studies were conducted in Africa. Two-way interactive nutritional counseling during pregnancy may improve dietary caloric intake (mean difference [MD]: 81.65 calories, 95% confidence interval [CI], 15.37-147.93, three RCTs; I 2 = 42%; moderate certainty of evidence using GRADE assessment), may reduce hemorrhage (relative risk [RR]: 0.63; 95% CI, 0.25-1.54, two RCTs; I 2 = 40%; very low certainty of evidence using GRADE assessment), may improve protein (MD: 10.44 g, 95% CI, 1.83-19.05, two RCTs; I 2 = 95%; high certainty of evidence using GRADE assessment), fat intake (MD: 3.42 g, 95% CI, -0.20 to 7.04, two RCTs; I 2 = 0%; high certainty of evidence using GRADE assessment), and may improve gestational weight gain within recommendations (RR: 1.84; 95% CI, 1.10-3.09, three RCTs; I 2 = 69%). Nutrition counseling probably leads to the initiation of breastfeeding immediately after birth (RR: 1.72; 95% CI, 1.42-2.09, one RCT). There was little to no effect on reducing anemia (RR: 0.77; 95% CI, 0.50-1.20, three RCTs; I 2 = 67%; very low certainty of evidence using GRADE assessment) risk of stillbirths (RR: 0.81; 95% CI, 0.52-1.27, three RCTs; I 2 = 0%; moderate certainty of evidence using GRADE assessment) and risk of cesarean section delivery (RR: 0.96; 95% CI, 0.76-1.20, four RCTs; I 2 = 36%; moderate certainty of evidence using GRADE assessment).

Authors’ Conclusions

Our review highlights improvements in maternal behavioral and health outcomes through interactive nutrition counseling during pregnancy. However, we are uncertain about the effects of nutrition counseling due to the low certainty of evidence and a low number of studies for some key outcomes. Moreover, the effects on health equity remain unknown. More methodologically rigorous trials that focus on a precise selection of outcomes driven by the theory of change of nutrition counseling to improve maternal and infant behavioral and health outcomes and consider equity are required.

Prevalence and factors associated with anemia in women of reproductive age across low- and middle-income countries based on national data

Anemia is a global threat among women of reproductive age (WRA), or 15-49 years old women, both in developed and developing countries. Prevalence of anemia in WRA is higher by fourfold in developing countries, based on extensive studies and surveys conducted by WHO and UNICEF. However, there is limited studies that conducted pooled analysis of anemia prevalence in low resource countries. This study aimed to assess the prevalence and factors associated with anemia among women of reproductive age in low- and middle-income countries (LMICs). This study used secondary data from the Demographic and Health Survey (DHS) in 46 low- and middle-income countries during 2010-2021. Descriptive statistics of proportions between pregnant and non-pregnant mothers were assessed. Multilevel binary logistic regression was used to test the factors associated with anemia among women of reproductive age. A total of 881,148 women of childbearing age in LMICs were included. This study found a high prevalence of 45.20% (95% CI 41.21, 49.16) of anemia was observed in among pregnant women and 39.52% (95% CI 33.88, 45.15) anemia was observed in non-pregnant women. Educational status, wealth status, family size, media exposure, and residence were common factors significantly associated with anemia in both pregnant and non-pregnant women. The high global burden of anemia in LMICs continues to underline the need for unusual approaches and target interventions on an individual basis. Global commitment and movement to reduce the prevalence of anemia need to be revisited and redesigned for current circumstances.

Effect of Educational Handouts With Standard Therapy Versus Standard Therapy Alone on Compliance With Oral Iron Supplementation in Antenatal Women With Iron Deficiency Anemia: A Randomized Controlled Trial

Background Iron requirements rise dramatically throughout the second and third trimesters of pregnancy. Pregnant women are more susceptible to anemia because their need for iron increases during pregnancy, which is difficult to achieve through diet alone. Methodology A randomized controlled trial (non-blinded and parallel group) was undertaken with the recruitment of 174 women. However, 35 women were lost to follow-up, and the study was ultimately completed with 139 participants distributing 68 women in Group A (intervention group) and 71 women in Group B (non-interventional group). Educational handouts were explained to the participants with iron supplements in Group A and only supplements were given to Group B, and the participants were followed up till three months before the recruitment period. Compliance with iron supplementation and a rise in hemoglobin were noted. Results In this study, maximum women were in the 22-30 years age group and were almost evenly distributed with respect to parity with no statistically significant difference in the groups. All the participants were started with oral iron therapy. No additional parenteral iron therapy was given. Women in Group A showed good compliance for iron supplementation than those in Group B. It was determined that this difference was statistically insignificant (>0.05). In the majority of women, the reason for poor compliance was frustration to follow oral iron therapy daily (52.3% in Group A and 21.7% in Group B). There were other reasons like forgetfulness, heartburn, vomiting, constipation, and nausea as the reason for poor compliance. The hemoglobin levels were compared at the recruitment and a mean rise in hemoglobin levels was noted in groups A and B at the follow-up period after three months. There was a greater mean rise in hemoglobin concentration in Group A (1.28) than in Group B (0.63), which was statistically insignificant (>0.05). Conclusion The current study found that among pregnant women with iron-deficient anemia, instructional handouts did not promote compliance with oral iron treatment. The main reasons for low compliance were frustration with taking the oral drug, followed by forgetfulness, heartburn, vomiting, constipation, and nausea. In pregnant females with anemia brought on by iron deficiency, educational handouts did not enhance hemoglobin status.

Effect of Picture-based health education and counselling on knowledge and adherence to preconception Iron-folic acid supplementation among women planning to be pregnant in Eastern Ethiopia: a randomized controlled trial

The present study examined the effect of picture-based nutrition education on knowledge and adherence to pre-conception iron-folic acid supplement (IFAS) in Ethiopia, a country where there is a high burden of neural tube defects (NTDs) and anaemia. In eastern Ethiopia, a parallel randomised controlled trial design was employed among women planning to get pregnant. The interventional arm (n 122) received a preconception picture-based nutrition education and counselling along with an IFAS and the control arm (n 122) received only a preconception IFAS. The effects of the intervention between-group differences were assessed using a χ 2 and independent sample t-test. Bivariate and multivariable linear regression model was fitted to detect independent variables affecting the outcome. The outcome measures regarding the knowledge and adherence to the IFAS intake during the three months of the intervention period were deteremined. It was observed that large proportion of women in the intervention group (42⋅6 %) had an adherence to IFAS compared to the control group (3⋅3 %); (P < 0⋅0001). Based on bivariate and multivariable linear regression analyses, among NTDs affecting pregnancy, the history of spontaneous abortion and knowledge were independently associated with adherence to the IFAS (P < 0⋅05). Preconception nutrition education with regular follow-ups could be effective in improving knowledge and adherence to the IFAS intake. This intervention is very short, simple, cost-effective and has the potential for adaptation development to a large-scale implementation in the existing healthcare system in Ethiopia to prevent NTDs and adverse birth outcomes among women who plan to get pregnant. This clinical trial was registered on 6 April 2021 under the ClinicalTrials.gov with an identifier number PACTR202104543567379.

Effectiveness of Health Information Package Program on Knowledge and Compliance among Pregnant Women with Anemia: A Randomized Controlled Trial

Despite the availability of iron supplements during pregnancy for all pregnant women receiving antenatal care in Saudi Arabia, anemia remains to be a global public health concern leading to adverse maternal, fetal, and neonatal effects. We aimed to evaluate the effectiveness of the Health Information Package Program on the knowledge anemic pregnant women had about anemia, their compliance with iron and folic acid supplementation, and their hemoglobin levels. A single-blind randomized controlled trial was carried out in accordance with the Consolidated Standards of Reporting Trials (CONSORT) guidelines between January and May 2021. Pregnant women (n = 196) aged 18–45 years old and diagnosed with anemia during the first trimester of their pregnancy were randomly assigned into two groups: the intervention group (Health Information Package Program plus routine care, n = 98) and the control group (routine care only, n = 98). Knowledge, the ability to select appropriate food, and hemoglobin levels were assessed at baseline and after three months, while compliance with iron and folic acid supplementation was also measured at the end of three months. This study indicated that the post-education mean knowledge score, food selection ability score, compliance rate, and hemoglobin level were significantly higher for the intervention group than for the control group. The Health Information Package Program with regular follow-ups using the WhatsApp platform was an effective educational intervention for anemic pregnant women.

The Effect of Health Education on Dietary Knowledge and Practices of Pregnant Women in Jordan: A Quasi-Experimental Study

Background

Evidence reported inadequate dietary practices among pregnant women and recommended educating pregnant women about their diet to improve pregnancy outcomes. However, studies examining the effect of health education about dietary practices during pregnancy are lacking in Jordan.

Objective

To examine the effect of health education on the levels of dietary knowledge and practices among pregnant women in Jordan.

Methods

A quasi-experimental design (pretest-posttest control group) was used. A consecutive sample of 195 pregnant women was recruited from four public health centers in Jordan; two health centers formed the intervention group (n=95) and two formed the control group (n=100). A structured questionnaire was used to assess dietary knowledge and practices before and after the intervention. The intervention group received health education for one month, while the control group received routine antenatal care. Data were collected from September to November 2019.

Results

After health education, the intervention group recorded significantly higher dietary knowledge score (mean= 19.30, SD= 0.88) compared to the control group score (mean= 14.36, SD= 2.11), p < 0.001. In addition, the intervention group reported significantly higher dietary practices score (mean= 8.70, SD= 1.16) compared to the control group score (mean= 7.02, SD= 1.66), p < 0.001. In particular, the intervention group recorded a significant increase in dietary knowledge score from the pretest (mean= 14.60, SD= 2.53) to posttest (mean= 19.30, SD= 0.88), as well as practices score from the pretest (mean= 6.69, SD= 1.97) to posttest (mean= 8.70, SD= 1.16), p < 0.001.

Conclusion

Providing health education concerning dietary knowledge and practices in the care of pregnant women may improve their knowledge and practices. Nurses and midwives in primary care centers have an essential role in assessing this knowledge and providing health education for pregnant women.

Interventions to increase adherence to micronutrient supplementation during pregnancy: a systematic review

Prenatal micronutrient supplements are cost‐effective in reducing nutritional deficiencies and adverse pregnancy and birth outcomes. However, poor adherence remains a potential barrier to the successful implementation of these supplementation programs. This systematic review assessed the effectiveness of interventions designed to increase adherence to prenatal micronutrient supplementation. Following the Cochrane Collaboration Methodology, literature searches were conducted in six electronic databases and gray literature (on July 24, 2020), and abstract screening, data extraction, and risk of bias assessment were conducted independently by two reviewers. We included 22 studies. Interventions that resulted in increased adherence were most of the education‐based strategies, consumption monitoring by volunteer health workers or family members, SMS reminders, free provision of supplements, a multicomponent intervention with community mobilization, and a participatory action research intervention. In several studies, increased adherence was accompanied by beneficial effects on pregnancy and birth outcomes. Given the heterogeneity of study designs and methods used to define and measure adherence, a meta‐analysis was not appropriate. We identified several potentially effective strategies to improve supplementation adherence, which may need to be adapted to specific contexts when considered for program implementation. However, additional high‐quality studies are critically needed to effectively guide policies and programs.

Baseline iron and low-grade inflammation modulate the effectiveness of iron supplementation: evidence from follow-up of pregnant Sri Lankan women

PURPOSE

We evaluated the effectiveness of iron supplementation in relation to baseline iron and inflammatory status of pregnant women and their offspring in Sri Lanka.

METHODS

Apparently healthy women aged 18-36 years at < 12 weeks of gestation prior to receiving any supplementation were randomly recruited at the antenatal clinics. They received 60 mg of elemental iron in combined iron-folic acid pills from 12 weeks of gestation until delivery via the National Maternal Supplementation Programme. Serum ferritins (SF), hemoglobin and high-sensitive C-reactive protein (hs-CRP) were assessed. The women were grouped as iron sufficient-inflammation (+), iron sufficient-inflammation (-), iron deficient-inflammation (+) and iron deficient-inflammation (-) based on their baseline iron stores and low-grade inflammation (hs-CRP > 5 < 10 mg/L) at baseline and late pregnancy.

RESULTS

Despite supplementation, SF in the iron sufficient-inflammation (+) women reduced significantly (p = 0.037) to deficiency state (SF < 30 µg/L) at mid-pregnancy. Whereas no significant changes were noted in the SF in iron sufficient-inflammation (-) women (p > 0.05). They maintained their stores at sufficient state until delivery. The cord SF was higher (p < 0.001) in iron sufficient-inflammation (-) than the inflammation (+) women. 96.4% of the iron deficient women remained deficient until delivery regardless of their inflammatory state. Low-grade inflammation was higher (p < 0.001) in women with baseline BMI > 25 kg/m². Whereas inflammation at late pregnancy was higher (p < 0.001) in women who gained weight in excess of the recommended, regardless of their baseline BMI.

CONCLUSION

Iron status prior to supplementation and low-grade inflammation associated with BMI > 25 kg/m² and excess weight gain during pregnancy appear to modulate the effectiveness of iron supplementation.