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

The Effects of Maternal Iron and Folate Supplementation on Pregnancy and Infant Outcomes in Africa: A Systematic Review

BACKGROUND

Iron and folate deficiency are prevalent in pregnant women in Africa. However, limited research exists on the differential effect of oral iron-only, folate-only, or Iron Folic Acid (IFA) supplementation on adverse pregnancy and infant outcomes. This systematic review addresses this gap, focusing on studies conducted in Africa with limited healthcare access. Understanding these differential effects could lead to more targeted and potentially cost-effective interventions to improve maternal and child health in these settings.

METHODS

A systematic review was conducted following PRISMA guidelines. The primary exposures were oral iron-only, folate-only, or IFA oral supplementation during pregnancy, while the outcomes were adverse pregnancy and infant outcomes. A qualitative synthesis guided by methods without meta-analysis was performed.

RESULTS

Our qualitative synthesis analysed 10 articles reporting adverse pregnancy (adverse birth outcomes, stillbirths, and perinatal mortality) and infant outcomes (neonatal mortality). Consistently, iron-only supplementation demonstrated a reduction in perinatal death. However, evidence is insufficient to assess the relationship between iron-only and IFA supplementation with adverse birth outcomes, stillbirths, and neonatal mortality.

CONCLUSION

Findings suggested that iron-only supplementation during pregnancy may reduce perinatal mortality in African women. However, evidence remains limited regarding the effectiveness of both iron-only and IFA supplementation in reducing stillbirths, and neonatal mortality. Moreover, additional primary studies are necessary to comprehend the effects of iron-only, folate-only, and IFA supplementation on pregnancy outcomes and infant health in the African region, considering rurality and income level as effect modifiers.

Burden and determinants of anemia among lactating women in Ethiopia: evidence from demographic health survey

Globally one-third of global population are victims of anemia, significantly impacting maternal and infant health and linked to poor cognition, productivity, and mortality risks. We used randomly selected 4040 lactating mothers' record from nationally representative survey. Descriptive statistics were weighted, and the standard hemoglobin cutoff point (below 12 g/dl) was used. Bivariable and multivariable multilevel binary logistic regression model considering the individual and community-level factors associated with anemia was employed. Crude and adjusted odds ratios with a 95% confidence interval were reported. In Ethiopia, 32.3% (95% CI 30.9-33.7%) of lactating women were anemic, with 23.4% having mild, 7.3% moderate, and 1.2% severe anemia. Pastoral regions (Afar, Somalia, and Oromia region) had higher burden of anemia than the others. The advanced age of the mother above 45 years (AOR = 1.43 (1.11-1.82), unemployment (AOR = 1.19; 95% CI 1.08-1.32), household wealth index (AOR = 0.56; 95% CI 0.50-0.63), extended family size (AOR = 1.20; 95% CI 1.04-1.46), and not using family planning (AOR = 1.70; 95% CI 1.49-1.93) were significant factors associated with anemia. Anemia is a moderate public health problem and associated with location and other factors to be addressed via effective interventions.

Does oral iron and folate supplementation during pregnancy protect against adverse birth outcomes and reduced neonatal and infant mortality in Africa: A protocol for a systematic review and meta-analysis?

BACKGROUND

Globally, one-third of pregnant women are at risk of iron deficiency, particularly in the African region. While recent findings show that iron and folate supplementation can lower the risk of adverse birth outcomes and childhood mortality, our understanding of its impact in Africa remains incomplete due to insufficient evidence. This protocol outlines the systematic review steps to investigate the impact of oral iron and folate supplementation during pregnancy on adverse birth outcomes, neonatal mortality and infant mortality in Africa.

METHODS AND ANALYSIS

MEDLINE, PsycINFO, Embase, Scopus, CINAHL, Web of Science, and Cochrane databases were searched for published articles. Google Scholar and Advanced Google Search were used for gray literature and nonindexed articles. Oral iron and/or folate supplementation during pregnancy is the primary exposure. The review will focus on adverse birth outcomes, neonatal mortality and infant mortality. Both Cochrane Effective Practice and Organization of Care and Newcastle-Ottawa Scale risk of bias assessment tools will be used. Meta-analysis will be conducted if design and data analysis methodologies permit. This systematic review and meta-analysis will provide up-to-date evidence about iron and folate supplementation's role in adverse birth outcomes, neonatal mortality and infant mortality in the African region.

ETHICS AND DISSEMINATION

This review will provide insights that help policymakers, program planners, researchers, and public health practitioners interested in working in the region.

PROSPERO REGISTRATION NUMBER

CRD42023452588.

Determinants of severity levels of anemia among pregnant women in Sub-Saharan Africa: multilevel analysis

Background

Anemia is a severe public health problem affecting 54% of pregnant women in SSA Yet, only a limited number of studies have provided a partial assessment of the pooled prevalence and related determinants of the severity levels of anemia in pregnant women in SSA. Therefore, this study provides the most recent estimates of anemia severity levels and related determinants.

Methods

The most recent Demographic Health Survey (DHS) dataset of 21 Sub-Saharan African countries which were collected between 2015 and 2022 were used. A total of 14,098 pregnant women were included. Multilevel ordinal logistic regression was used.

Results

The pooled prevalence of anemia was 51.26%. Pregnant women who were in the old age groups, and who have attended secondary and higher education were less likely to be at higher levels of anemia. Those women who have given birth to >1 children in the last 5 years, pregnant women in second and third trimester and living in poorest households had greater odds of being at higher levels of anemia.

Conclusion

In Sub-Saharan Africa, anemia is a severe public health concern for pregnant mothers. When developing and implementing strategies for the prevention and control of anemia, it is imperative to take into account the individual and community circumstances. Programs for the prevention and control of anemia should incorporate the economic and educational empowerment of women.

Determinants of compliance to iron folate supplementation among pregnant women attending antenatal care in public health facilities of South West Ethiopia: A case-control study

Background

The prevalence of anemia among pregnant women remains high globally, particularly in low-income settings. Iron and folic acid supplementation (IFAS) during pregnancy is the most widely employed strategy to alleviate adverse pregnancy outcomes. This study aimed to explore the determinants of compliance with iron supplementation in the study area.

Aim

To identify determinants of IFAS compliance among pregnant women attending antenatal care (ANC) in Mettu town, South West Ethiopia, in 2021.

Methods

A facility-based, unmatched case-control study was conducted from May to July 2021 with a total sample size of 344 (115 cases and 229 controls). Cases and controls were selected using systematic random sampling. Data was collected using a structured, pretested interviewer-administered questionnaire, entered into Epi-data software version 3.1, and exported to SPSS version 23 for analysis. Variables with p < 0.25 during bivariate analyses were entered into a multivariable logistic regression model. Then, variables with a p < 0.05 at 95% confidence interval (CI) were declared to be statistically significant determinants of IFAS. The odds ratio was used to indicate the strength of the association.

Result

Having Previous history of anaemia (adjusted odds ratio [AOR] = 5.8, 95% CI [2.5-13.6], p < 0.01), having good knowledge about IFAS (AOR = 3.3, 95% CI [1.7-6.7], p < 0.001), being a government employee (AOR = 5.2 [2.4-11.5], p < 0.01], and receiving counseling service during ANC (2.495% CI [1.3-4.7] p < 0.01) were among determinants of adherence to IFAS.

Conclusions

Maternal knowledge about IFAS, counseling about IFAS, occupation, and history of anaemia were found to be significantly associated factors with compliance with iron folate supplementation during pregnancy. This implies that adherence to IFAS can be improved through improving maternal knowledge about importance of IFAS, quality counseling services and strengthening an overall ANC follow-up services.

Iron folic acid supplementation adherence level and its associated factors among pregnant women in Ethiopia: a multilevel complex data analysis of 2019 Ethiopian mini demographic and health survey data

Background

Iron and folic acid deficiency is a worldwide public health concern, particularly in low and middle-income countries. In Ethiopia, adherence to iron and folic acid supplements is still very low. Despite the fact that a number of studies on IFA supplementation have been conducted in Ethiopia, they do not indicate a nationwide problem and do not use advanced models to demonstrate clustering effects. The purpose of this study was to assess the level of non-adherence to iron folic acid supplementation and predictors among pregnant women in Ethiopia.

Objective

To assess iron folic acid supplementation adherence level and its associated factors among pregnant women in Ethiopia using data from the 2019 Mini-Ethiopian demographic health survey.

Methods

The Mini Ethiopian Demographic and Health Survey 2019 data were obtained from the official database website of the Demographic and Health Survey program (http://dhsprogram.com). The analysis included a sample of 2,356 weighted study participants. A multivariable multilevel mixed-effects logistic regression model was used Variables with p-values less than 5%) was reported as statistically significant variables in the multivariable analysis.

Results

The proportion of mothers who did not adhere to iron and folic acid supplements was 81.03% (95 %CI, 79.39, and 82.56). Birth interval less than 2 years [AOR: 2.03; 95% CI: 1.12, 3.66], women ever born less than six children [AOR: 1.99; 95% CI: 1.09, 3.64], starting ANC visit during first trimester [AOR: 2.74; 95 %CI: 1.03, 7.30], region [AOR = 0.24; 95% CI: 0.10], and having a high no ANC visit in the community [AOR = 1.77; 95% CI: 1.08, 2.88] were statistically significant factors. There was Intra-Custer Correlation (ICC = 17.72%), indicating that 17.72% variability in non-adherence levels was due to clusters.

Conclusion and recommendation

In Ethiopia, nearly four out of every five pregnant women did not receive iron folic acid supplementation for the recommended periods. Birth intervals, number of children, timing of ANC visits, region, and community level no ANC service were significant factors for non-adherence IFAS. As a result, the community, govern metal and non-governmental sectors enacting on health should focus on reducing non-adherence through tailored interventions on factors that influence it.

Evaluation of dietary composition between hemoglobin categories, total body iron content and adherence to multi-micronutrients in preschooler residents of the highlands of Puno, Peru

BACKGROUND

The anemia prevalence is higher in highlands populations. It is assumed that iron deficiency anemia (IDA) in children is mainly due to low dietary intake. However, other suggest that high prevalence of anemia is due to an inappropriate hemoglobin (Hb) adjustment for altitude.

MATERIALS AND METHODS

Cross-sectional study conducted in 338 preschoolers (PSC) from Puno-Peru. Hb was measured in whole blood, and ferritin, Soluble transferrin receptor, and Interleukin 6 in serum.The dietary iron intake was assessed by 24-h dietary recall, using NutriCap Software. Hb concentration was assessed as adjusted or unadjusted for altitude.

RESULTS

With unadjusted Hb, the anemia prevalence was 4.7%, whereas after Hb correction, the prevalence raised-up to 65.6% (p < 0.001). Reciprocally, erythrocytosis proportion decreased from 20.35 to 0.30% (p < 0.001). Total Body Iron (TBI) showed that 7.44% had ID and 0.32% had IDA. PSC with normal unadjusted Hb levels have more protein and micronutrients intake than anemic ones. PSC with erythrocytosis consumed less fat, and more niacin and ascorbic acid than anemics. Total iron intake was lower in anemic than the other groups, but without statistical significance due to the standard deviation of the data in a small number of anemic PSC (n = 16). TBI, unadjusted Hb, and adjusted Hb were not different between groups consuming or not multimicronutrients.

CONCLUSIONS

The consumption of iron and iron status in children who live at high altitude is adequate, and that anemia could be due to other micronutrient deficiencies and/or that the adjustment of Hb by altitude is inappropriate.

Adherence to Iron and Folic Acid Supplementation Among Pregnant Women From Northern Ghana

Iron and folic Acid (IFA) supplementation is an effective intervention for reducing the incidence of anaemia during pregnancy. The WHO recommends at least 6 months intake of IFA to pregnant women. However, in Ghana some women experience challenges with adhering to IFA supplementation. The main objective of the study was to assess the level of adherence to iron and folic acid supplementation and its associated factors among pregnant women in a peri-urban municipality in Northern Ghana. A cross-sectional study was conducted from March to December 2021 among 400 pregnant women who attended ANC in Sagnarigu municipality in Ghana and were selected through a 3-stage random sampling technique. A structured questionnaire was used to collect data. The data were analysed using descriptive statistics, univariate and binary logistic regression statistical tools. Self-reported level of adherence to iron and folic acid supplementation was 84.5%. Knowledge of iron and folic acid supplementation (AOR = 0.08: 021, 0.343) was associated with adherence. Three other factors: time of first antenatal visit (AOR = 0.32: 0.153, 0.649) having history of anaemia [AOR = 2.67: 1.373, 5.201] having side effects of IFA [AOR = 3.70, CI: (1.756, 7.793)], and having knowledge of management of side effects of iron and folic acid supplementation (AOR = 0.08: 021, 0.343) were found to be significantly associated with adherence. Adherence to iron and folic supplementation among the pregnant women was generally frequent. Strategies to increase iron and folic acid supplementation adherence among pregnant women could focus on encouraging pregnant women to have early ANC visits and educating them on how to manage side effects.

Is It Time to Alter the Standard of Care for Iron Deficiency/Iron Deficiency Anemia in Reproductive-Age Women?

Two billion people worldwide suffer from anemia, with reproductive-age women being disproportionately affected. Iron plays a crucial role in cellular function and impacts cognition, physical function, and quality of life. Iron deficiency (ID) and iron deficiency anemia (IDA) are associated with adverse effects on pregnancy and fetal development. Oral iron supplementation has been the standard treatment for decades, often producing sub-optimal outcomes. Many babies are still being born with ID and suffer adverse sequelae due to inadequate iron levels in the mothers. Is it time to consider a broad scale-up of parenteral iron as a new standard of care?

Prevalence and determinants of anaemia among pregnant women in a high malaria transmission setting: a cross-sectional study in rural Burkina Faso

Introduction

anemia, the commonest nutritional deficiency disorder among pregnant women in sub-Saharan Africa, is associated with severe peripartum complications. Its regular monitoring is necessary to timely inform clinical and preventive decision-making. The aim of this study was to assess the prevalence and determinants of anemia among pregnant women in rural areas of Burkina Faso.

Methods

between August 2019 and March 2020, a cross-sectional study was conducted to collect maternal sociodemographic, gynaeco-obstetric, and medical characteristics by face-to-face interview or by review of antenatal care books. In addition, maternal malaria was diagnosed by standard microscopy and the hemoglobin levels (Hb) measured by spectrophotometry. The proportion of anaemia (Hb<11.0 g/dL), moderate (7.0

Results

of 594 pregnant women assessed, the mean hemoglobin level (± standard deviation) was 10.7 (±0.1) g/dL, and the prevalence of anemia was 54.4% (323/594). The proportion of moderate, and severe anemia among pregnant women was 49.2% (95% CI: 45.1%-53.2%), and 5.2% (95% CI: 3.7%-7.3%) respectively. Multivariate analysis showed that the young maternal age (<20 years old) (adjusted OR (aOR): 1.5, 95% CI: 1.1-2.3) and the presence of malaria (aOR: 2.0, 95% CI: 1.3-3.2) were independently associated with the presence of maternal anemia.

Conclusion

anemia remains common in the study setting and interventions to strengthen malaria prevention in pregnancy, particularly among young adolescent pregnant women, are required to prevent maternal anemia.

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Key Words

• Anaemia
• Burkina Faso
• malaria
• pregnancy
• rural area

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MESH Headings

• Adolescent
• Female
• Pregnancy
• Humans
• Young Adult
• Adult
• Cross-Sectional Studies
• Pregnant Women
• Burkina Faso/epidemiology
• Prevalence
• Risk Factors
• Malaria/complications
• Malaria/epidemiology
• Malaria/prevention & control
• Anemia/epidemiology
• Anemia/etiology
• Pregnancy Complications, Hematologic/epidemiology
• Pregnancy Complications, Hematologic/etiology
• Hemoglobins/analysis

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Affiliation(s)

Moussa Lingani Institut de Recherche en Sciences de la Santé Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
Serge Henri Zango Institut de Recherche en Sciences de la Santé Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
Innocent Valéa Institut de Recherche en Sciences de la Santé Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
Sékou Samadoulougou Evaluation Platform on Obesity Prevention, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
Moussa Abdel Sanou Institut de Recherche en Sciences de la Santé Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
Hermann Sorgho Institut de Recherche en Sciences de la Santé Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
Edmond Sawadogo Institut de Recherche en Sciences de la Santé Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
Michèle Dramaix École de Santé Publique, Université Libre de Bruxelles, Route de Lennik, Bruxelles, Belgique
Philippe Donnen École de Santé Publique, Université Libre de Bruxelles, Route de Lennik, Bruxelles, Belgique
Robert Annie Epidemiology and Biostatistics Research Division, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Clos Chapelle-aux-Champs, Brussels, Belgique
Halidou Tinto Institut de Recherche en Sciences de la Santé Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso

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Postpartum hemorrhage in Sub-Saharan Africa-a prospective study in metropolitan Mozambique

BACKGROUND

Estimates indicate approximately ≈500 to 1000 maternal deaths per 100,000 live births in Sub-Saharan Africa (SSA) (vs ≈5-20 in developed countries). Postpartum hemorrhage (PPH) seems a major contributor to maternal mortality (MM), but there are no comprehensive data for the region.

OBJECTIVES

Analyze MM, PPH, and associated risk factors.

METHODS

We collected prospective data on MM, PPH, and associated risk factors in metropolitan Mozambique. We recorded consecutive deliveries at the Maputo Central Hospital between February 2019 and January 2021. Data included age, HIV status, parity, delivery mode, notes, vital signs, laboratory values, and fetal parameters. PPH was determined by charted diagnosis, blood loss of >500 mL, transfusion, and/or notes indicating significant bleeding.

RESULTS

Of 8799 deliveries, ≈40% occurred in women residing outside Maputo City ("nonlocal"), with similar demographic characteristics between local and nonlocal women. However, compared with local women, nonlocal women had worse outcomes, including higher rates of MM (1.52% vs 0.78%; P =.0012) and PPH (16.51% vs 12.39%; P <.0001), whereby PPH was strongly associated with MM (adjusted odds ratio = 5.56; P <.0001). Almost all women with uterine atony (≈1%) experienced PPH. For women receiving laboratory tests on admission (drawn only if in distress; local, n = 561; nonlocal, n = 514), both cohorts revealed similar distributions of hemoglobin levels and platelet counts. Prepartum anemia (≈57%) and thrombocytopenia (≈21%) were prominent risk factors for PPH; risk increased with increasing severity and was additive in the presence of both.

CONCLUSIONS

PPH is a serious problem in Maputo province, a metropolitan area of SSA, portending high MM. Identification of correctable risk factors, including anemia, should catalyze the development of region-specific prevention protocols.

Trends and determinants of anemia in children 6-59 months and women of reproductive age in Chad from 2016 to 2021

BACKGROUND

Hemoglobin assessments in children and women have been conducted annually in Chad since 2016 through the Standardized Monitoring and Assessment of Relief and Transitions (SMART) cross-sectional surveys. This analysis aims to characterize national and sub-national trends in anemia among children under five and women of reproductive age from 2016 to 2021 and to compare risk factors for anemia before and during the COVID-19 pandemic.

METHODS

Hemoglobin concentrations were measured in approximately half of the 12,000 to 15,000 included households each year, except for 2020 when hemoglobin tests were omitted. For children 6 to 59 months of age, anemia was defined as hemoglobin less than 11.0 g/dL. Anemia was defined as hemoglobin less than 11.0 g/dL and 12.0 g/dL for pregnant women and non-pregnant women, respectively. Trends were stratified by agroecological zone, and tests of proportions were used to assess statistical significance. Simple and multivariate logistic regression models were conducted for 2019 and 2021 to identify risk factors for anemia.

RESULTS

Reductions in anemia over the 6-year period were significant among women (47.6-30.8%, p = 0.000) and children (68.6-59.6%, p = 0.000). The Sudanian zone had consistently higher rates, particularly in children, compared to the Sahelian and Saharan zones. Significant declines in women's anemia were observed in all zones from 2019 to 2021, but this global decline was not observed among children, where rates in the Saharan zone significantly increased. In 2019, only minimum dietary diversity significantly reduced the odds of anemia in children (AOR: 0.65, 95%CI: 0.46-0.92), whereas in 2021, improvements in all diet indicators were associated with lower odds of anemia. Improved household socio-economic factors, including head of household literacy, were associated with lower odds of anemia in children (2019 AOR: 0.76, 95%CI: 0.67, 0.88) and women (2019 AOR: 0.75, 95%CI: 0.65, 0.87; 2021 AOR: 0.81, 95%CI: 0.70, 0.93).

CONCLUSIONS

Anemia declined significantly in Chad among women of reproductive age and children from 2016 to 2021, but the national prevalence of 60% among children remains unacceptably high. Sub-national differences in anemia rates underline the need to identify and address regional causes of anemia while strengthening national level programs.

Adherence to iron supplement intake during pregnancy and associated factors in Ethiopia: Further analysis of a national population-based study

Iron deficiency during pregnancy is a risk factor for anemia, preterm delivery, and low birth weight. Poor adherence to iron supplement intake remains a problem in many countries including Ethiopia. This analysis aimed at determining the proportion of adherence to iron supplement intake and its associated factors among pregnant women in Ethiopia. We used the data from the 2019 Ethiopia Mini Demographic and Health Survey (EMDHS), which is a cross-sectional and nationally representative survey. A weighted sample of 3927 pregnant women was included in the study. Bivariate and multivariable binary logistic regression analyses were performed to identify factors associated with adherence to iron supplement intake. Adjusted odds ratio (AOR) with a 95% confidence interval (CI) and p-value <.05 were used to declare statistical significance. Our analysis revealed that out of 2356 (60.0%) pregnant women who took iron supplements during their most recent pregnancy, only 417 (17.7%; 95% CI: 0.162-0.193) adhered to the WHO-recommended iron intake for 90 days or more. The subnational regions, level of education, literacy, the timing of first antenatal care booking, and past place of delivery were significantly associated with iron supplement intake. Interventions to enhance the uptake of iron supplementation better focus on improving women's education and literacy, early initiation and frequency of ANC visits, and institutional delivery. Raising community awareness through educating pregnant women is also recommended to improve adherence to iron supplement intake.

Comprehensive Approach for Improving Adherence to Prenatal Iron and Folic Acid Supplements Based on Intervention Studies in Bangladesh, Burkina Faso, Ethiopia, and India

BACKGROUND

The World Health Organization recommends daily iron and folic acid (IFA) supplementation during pregnancy, but consumption remains low, and high prevalence of anemia among pregnant women (PW) persists.

OBJECTIVES

This study aims to (1) examine factors at the health system, community, and individual levels, which influence adherence to IFA supplements; and (2) describe a comprehensive approach for designing interventions to improve adherence based on lessons learned from 4 country experiences.

METHODS

We conducted literature search, formative research, and baseline surveys in Bangladesh, Burkina Faso, Ethiopia, and India and applied health systems strengthening and social and behavior change principles to design interventions. The interventions addressed underlying barriers at the individual, community, and health system levels. Interventions were further adapted for integration into existing large-scale antenatal care programs through continuous monitoring.

RESULTS

Key factors related to low adherence were lack of operational protocols to implement policies, supply chain bottlenecks, low capacity to counsel women, negative social norms, and individual cognitive barriers. We reinforced antenatal care services and linked them with community workers and families to address knowledge, beliefs, self-efficacy, and perceived social norms. Evaluations showed that adherence improved in all countries. Based on implementation lessons, we developed a program pathway and details of interventions for mobilizing health systems and community platforms for improving adherence.

CONCLUSION

A proven process for designing interventions to address IFA supplement adherence will contribute to achieving global nutrition targets for anemia reduction in PW. This evidence-based comprehensive approach may be applied in other countries with high anemia prevalence and low IFA adherence.

Ferric carboxymaltose versus standard-of-care oral iron to treat second-trimester anaemia in Malawian pregnant women: a randomised controlled trial

BACKGROUND

Anaemia affects 46% of pregnancies in Africa; oral iron is recommended by WHO but uptake and adherence are suboptimal. We tested a single dose of a modern intravenous iron formulation, ferric carboxymaltose, for anaemia treatment in Malawian pregnant women.

METHODS

In this open-label, individually randomised controlled trial, we enrolled women with a singleton pregnancy of 13-26 weeks' gestation in primary care and outpatient settings across two regions in southern Malawi. Women were eligible if they had capillary haemoglobin of less than 10·0 g/dL and negative malaria rapid diagnostic test. Participants were randomised by sealed envelope 1:1. Assessors for efficacy outcomes (laboratory parameters and birthweight) were masked to intervention; participants and study nurses were not masked. Participants were given ferric carboxymaltose up to 1000 mg (given once at enrolment in an outpatient primary care setting), or standard of care (60 mg elemental iron twice daily for 90 days), along with intermittent preventive malaria treatment. The primary maternal outcome was anaemia at 36 weeks' gestation. The primary neonatal outcome was birthweight. Analyses were performed in the intention-to-treat population for mothers and liveborn neonates, according to their randomisation group. Safety outcomes included incidence of adverse events during infusion and all adverse events from randomisation to 4 weeks' post partum. The trial is registered with ANZCTR, ACTRN12618001268235. The trial has completed follow-up.

FINDINGS

Between Nov 12, 2018, and March 2, 2021, 21 258 women were screened, and 862 randomly assigned to ferric carboxymaltose (n=430) or standard of care (n=432). Ferric carboxymaltose did not reduce anaemia prevalence at 36 weeks' gestation compared with standard of care (179 [52%] of 341 in the ferric carboxymaltose group vs 189 [57%] of 333 in the standard of care group; prevalence ratio [PR] 0·92, 95% CI 0·81 to 1·06; p=0·27). Anaemia prevalence was numerically lower in mothers randomly assigned to ferric carboxymaltose compared with standard of care at all timepoints, although significance was only observed at 4 weeks' post-treatment (PR 0·91 [0·85 to 0·97]). Birthweight did not differ between groups (mean difference -3·1 g [-75·0 to 68·9, p=0·93). There were no infusion-related serious adverse events or differences in adverse events by any organ class (including malaria; ≥1 adverse event: ferric carboxymaltose 183 [43%] of 430 vs standard of care 170 [39%] of 432; risk ratio 1·08 [0·92 to 1·27]; p=0·34).

INTERPRETATION

In this malaria-endemic sub-Saharan African setting, treatment of anaemic pregnant women with ferric carboxymaltose was safe but did not reduce anaemia prevalence at 36 weeks' gestation or increase birthweight.

FUNDING

Bill & Melinda Gates Foundation (INV-010612).

Adherence to iron and folate supplementation and associated factors among women attending antenatal care in public health facilities at Covid-19 pandemic in Ethiopia

Adhesion is the degree to which a patient complies with treatment recommendations made by a health care professional. The majority of pregnant women worldwide don't get the recommended amounts of iron and folic acid (30 to 60 mg of iron and 400 g of folic acid/day for 6 months) pregnant women are more likely to develop iron- and folic acid deficiency anemia. For iron and folate supplementation programs to be effective in Ethiopia, adherence is a significant issue. So, this study aimed to evaluate the level and barriers preventing women receiving antenatal care from taking iron and folate supplements. A phenomenological qualitative study design was added to a facility-based cross-sectional study. The sample was established using a double population proportion formula. For the quantitative and qualitative study, 308 pregnant women and the focal points for the health facilities were chosen at random, using systematic random sampling and purposive sampling techniques. For the quantitative study, a face-to-face interviewer-guided, pre-tested structured questionnaire was used; for the qualitative study, a semi-structured questionnaire was used. Data was entered twice, cross-checked by comparing the two separate entries in Epi Data version 7.2.2.6, and exported to SPSS version 25 for analysis. COR and AOR with 95% CI are used to evaluate the relationship between variables and control for confounding factors. Statistical significance was declared at a p-value < 0.05. All, 308 (100%) participants were involved. 56.5% of pregnant women attending an ANC clinic (95% CI: 51%-62.2%) adhered to Iron and folate supplementation. Mothers with primary education], Urban residents mothers, Mother who had four or more ANC visits, mothers who had registered for their first ANC at early gestational age, mothers who had good awareness about birth defects were independent predictors of adherence to Iron and folate supplementation. In our study, adherence to iron and folate supplementation was low relative to previous research findings. Promoting early and frequent ANC visits and improving pregnant women's awareness of anemia and birth defects through education is necessary to increase the adherence status.

Assessment of Iron-Folate Adherence and Associated Factors Among Pregnant Women in Public Health Facilities of Durame Town, Southern Ethiopia

Introduction

Iron deficiency anemia during pregnancy is a significant public health problem in low- and middle-income countries. The World Health Organization recommended a daily oral dose of iron and folic acid supplements throughout pregnancy. Poor adherence to iron and folic acid supplementation arises in pregnant women associated with serious adverse health outcomes.

Objective

This study aimed to assess iron-folate adherence and associated factors among pregnant women in public health facilities of Durame town, Southern Ethiopia, in 2022.

Methods

An institution-based cross-sectional study was conducted from March 1-30, 2022. A structured interviewer-administered questionnaire was used to interview a total sample size of 317 participants. Logistic regression analysis was computed, and variables with a p-value of less than 0.25 in the bivariate logistic regression analysis were selected for multivariable logistic regression analysis. Finally, significance was declared at p < .05 with 95%CI.

Results

The findings of this study showed that adherence to iron-folate among pregnant women was 180 (60%) (95%CI: 54-65.7). The odds of iron-folate adherence among women who had not had anemia in their current pregnancy were 63% (AOR = 0.37, 95%CI: 0.14-0.99) less likely to have adherence, and the odds of iron-folate adherence among women who had not heard about the disease anemia were 58% (AOR = 0.42, 95%CI: 0.22-0.81) less likely to have adherence.

Conclusion

Iron-folate adherence in Durame public health facilities was better compared to other studies even if it was not high enough to prevent anemia and folate deficiency. Women who had not had anemia in their current pregnancy and women who had not heard about the disease anemia were significantly associated with adherence to iron-folate. Thus, healthcare providers should provide health education on the enhancement of adherence to iron-folate utilization and the means how to prevent iron-folate deficiency during their clients' pregnancy.

Trend of adherence to iron supplementation during pregnancy among Ethiopian women based on Ethiopian demographic and health surveys: A Multivariable decomposition analysis

Background

Iron deficiency is one of the significant factors of anemia during pregnancy. Iron supplementation is the main method of prevention and control of iron deficiency anemia, and its effectiveness depends on adherence to the iron supplementation.

Methods

This study was based on a secondary analysis of 2005, 2011, and 2016 EDHS data. After the data was weighted using sampling weight, 696, 1,282, and 3,096 in 2005, 2011, and 2016 EDHS data, respectively, were used for the final analysis. The data were edited, cleaned, coded, managed, and analyzed using StataCorp version 16 software. A logit-based multivariable decomposition analysis was used to identify variables significantly associated with the change in the adherence level during pregnancy.

Results

Adherence levels increased from 1.1% (95% CI; 0.4, 2.7) in 2005 EDHS to 12.4% (95% CI; 10.9, 14.1) in 2016 EDHS. About 30.9% of the overall change in the adherence level to iron supplement use during pregnancy was due to the difference in women's sociodemographic-related variables. After adjusting for these compositional changes, ~69.1% of the change in the adherence level was because of the difference in the coefficients (behavior-related variables). Among the behavioral characteristics, women's age-group, rich wealth index, and secondary and above-secondary educational status of their husbands had a statistically significant effect on the positive change in the adherence level of pregnant mothers.

Conclusion

The adherence level to iron supplement use during pregnancy has increased significantly over the last decade in Ethiopia. Both the compositional and behavioral characteristics of women play a major role in the increasing trend of adherence levels.

Poor adherence to iron-folic acid supplementation and associated factors among pregnant women who had at least four antenatal care in Ethiopia. A community-based cross-sectional study

Background

In developing countries, including Ethiopia, maternal mortality is a major public health concern. The Ethiopian Demographic Health Survey (EDHS) reported that the maternal mortality ratio (MMR) was 420 per 100,000 live births in 2016. Iron-folic acid supplementation (IFAS) is a key intervention to reduce these deaths. Therefore, this study aimed to assess the magnitude of poor adherence to IFAS and associated factors among pregnant women who had at least four antenatal care in Ethiopia.

Methods

Secondary data analysis was used using 2016 Ethiopian Demographic and Health Survey (EDHS). We analyzed the data using Stata version 14. To identify factors associated with poor adherence to IFAS, a multilevel mixed-effect logistic regression model was fitted. Variables with a p < 0.05 in the multilevel mixed-effect logistic regression model were declared as significant factors associated with poor adherence to IFAS.

Result

The magnitude of poor adherence to IFAS was 82.87% (95% CI: 80.96-84.65). Women education; primary [adjusted odds ratio (AOR) = 0.48; 95% CI: 0.31-0.75] and secondary (AOR = 0.52; 95% CI: 0.29-0.96), husband education; primary (AOR = 0.56; 95% CI: 0.36-0.86) and secondary (AOR = 0.51; 95% CI: 0.29-0.95), and community media exposure (AOR = 0.47; 95% CI: 0.27-0.79) were significantly associated with poor adherence to IFAS.

Conclusion

In the current study, more than eight out of ten pregnant women who had at least four antenatal care had poor adherence to IFAS. Thus, promoting maternal and husband education and establishing community media with a priority on iron-folic acid supplementation and health-related programs are essential strategies to reduce poor adherence to IFAS.

An implementation research programme to support an intravenous iron intervention for pregnant women with moderate and severe anaemia in Malawi: study protocol

Background

Antenatal iron supplementation is critical to maternal and child health; however, access and adherence to oral iron are inconsistent in many low- and middle-income countries (LMICs). Modern intravenous (IV) iron products have become available in high-income clinical settings and provide an opportunity to deliver high doses of iron in a single-short infusion during pregnancy. However, there is limited knowledge of the drivers and barriers for such an intervention to be effectively delivered and upscaled in LMICs. In this study protocol, we describe the implementation research programme to support an IV iron intervention in Malawi for pregnant women with moderate and severe anaemia.

Methods

The implementation research programme has three phases, each guided by implementation science conceptual frameworks. In Phase 1, we will conduct formative research (context assessment of the health system with key informant interviews) to determine how IV iron can be effectively introduced into routine antenatal care. We will use the findings to co-develop potential strategies with end-users and healthcare providers to improve intervention implementation. In Phase 2, we will disseminate the implementation strategies to support the uptake and delivery of the intervention in the study settings. In Phase 3, the intervention will be implemented, and we will conduct formative evaluation (interviews with end-users, healthcare providers, and analysis of health services data) to investigate the feasibility and acceptability of the intervention and strategies. We will also identify processes and contextual factors that facilitate or impede the delivery and uptake of IV iron.

Discussion

In LMICs, modern IV iron products present a novel opportunity to rapidly cure moderate and severe anaemia in pregnancy, thereby improving maternal and child health outcomes. This implementation research programme will provide guidance and recommendations on how best an IV iron intervention for pregnant women with anaemia can be implemented in an LMIC setting like Malawi. We will develop locally relevant and culturally appropriate implementation strategies by engaging with key stakeholders (pregnant women, healthcare providers, and policymakers) and identifying factors likely to facilitate successful implementation. The findings of this research can guide the implementation of an IV iron intervention in Malawi and other LMICs.

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.

Immediate postpartum anemia and associated factors among women admitted to maternity ward at public hospitals in Harari Regional State, Eastern Ethiopia: A facility-based cross-sectional study

Background

Anemia in the postpartum period remains a considerable public health problem in developing countries, particularly in sub-Saharan Africa. It is the most common indirect cause of maternal morbidity and mortality. It is also a major health problem in women of reproductive age, affecting their quality of life, occupational capacity, lactation, and immunological function. Immediate postpartum anemia has a significant impact on women's quality of life, although its predictors have received little attention in Ethiopia, notably in Harari Regional State. Therefore, this study aimed to determine its magnitude and contributing factors in Eastern Ethiopia.

Methods

A facility-based cross-sectional study was conducted from June 1^st to August 30^th, 2021, among 484 postpartum women admitted to two public hospitals in Harari Regional State, Eastern Ethiopia. Data were collected using a pre-tested, structured interviewer-administered questionnaire. About 2 mL of blood samples were collected and analyzed using the cell-Dyne 1,800 machine. The collected data were entered into Epi-Data version 4.6 and analyzed using SPSS version 25. A multivariable logistic regression analysis was conducted to estimate the effect of independent variables on immediate postpartum anemia. An adjusted odds ratio (AOR) with a 95% confidence interval (CI) was computed to report the presence of the association. Statistical significance was declared at a p-value of < 0.05.

Results

The overall magnitude of immediate postpartum anemia was 28.1% [95% CI (23.7, 32.1)]. Lack of formal education [AOR: 3.92; 95% CI: (1.85, 8.33)], having antenatal care < 4 visits [AOR: 3.18; 95% CI: (1.53, 6.61)], a history of cesarean delivery [AOR: 3.40; 95% CI: (1.89, 6.10)], a history of maternal blood loss [AOR: 4.78; 95% CI: (2.22, 10.30)], pre-delivery Hgb level < 11 g/dl [AOR:5.46; 95% CI: (3.09,9.67)], and having no iron-folate supplementation [AOR:3.27; 95% CI: (1.31, 8.15)] were factors statistically associated with immediate postpartum anemia.

Conclusions

In this study, nearly one-third of mothers admitted for postpartum care developed anemia within 48 h of giving birth. Women's educational level, frequency of antenatal care, mode of delivery, a history of maternal blood loss, pre-delivery hemoglobin level, and iron-folate supplementation status were identified as immediate postpartum anemia risk factors. Therefore, promoting the benefits of adequate antenatal care and iron-folate supplementation during pregnancy is crucial to avoiding the risks of postpartum anemia.

Geographical disparities and determinants of adherence to iron folate supplementation among pregnant women in Ethiopia: spatial and multilevel analysis of the Ethiopian Mini Demographic and Health Survey of 2019

OBJECTIVE

This study aimed to investigate geographic disparities and determinants of adherence to iron and folate supplementation among pregnant women in Ethiopia.

METHOD

A secondary data analysis was performed using data from the Ethiopian Mini Demographic and Health Survey 2019. A total of 2235 pregnant women aged 15-49 years were included in the analysis. ArcGIS V.10.8 and SaTScan V.9.6 were used for spatial analysis. Multilevel logistic regression analysis was used to determinants.

RESULT

Of the total number of participants, 80.3% of pregnant mothers took iron and folate supplements for less than the recommended days. Adherence to iron folate supplementation among pregnant women in Ethiopia was spatially clustered with Moran's global I=0.15868. The SaTScan analysis identified the most likely significant clusters found in the eastern Tigray, northeast Amhara and northwest Afar regions. Multivariable multilevel analysis showed that mothers who were living apart from their partner (adjusted OR (AOR)=10.05, 95% CI 1.84 to 55.04), had antenatal care (ANC) visits at least four times (AOR=0.53, 95% CI 0.41 to 0.69), a higher education level (AOR=0.39, 95% CI 0.25 to 0.63), big distance from health facilities (AOR=1.7, 95% CI 1.51 to 1.97) were significant factors of adherence to iron-folate supplementation. Mothers living in the Amhara and Addis Ababa regions were 0.35 (AOR=0.35, 95% CI 0.19 to 0.621), and 0.29 (AOR=0.29, 95% CI 0.15 to 0.7) times lower iron-folate supplementation intake than mother's in Tigray region.

CONCLUSION

In this study, 8 out of 10 pregnant women did not take iron and folate supplements during the recommended period. As a result, health education activities were necessary to raise awareness among women and the community about the importance of iron folate supplementation during pregnancy, and public health programmes should increase iron folate supplementation through women's education, ANC visits and mothers living in low-iron areas.

Prevalence and determinants of meeting minimum dietary diversity among children aged 6-23 months in three sub-Saharan African Countries: The Demographic and Health Surveys, 2019-2020

Background

Dietary diversity is an indicator of nutritional adequacy, which plays a significant role in child growth and development. Lack of adequate nutrition is associated with suboptimal brain development, lower school performance, and increased risk of mortality and chronic diseases. We aimed to determine the prevalence and determinants of meeting minimum dietary diversity (MDD), defined as consuming at least five out of eight basic food groups in the previous 24-h in three sub-Saharan African countries.

Methods

A weighted population-based cross-sectional study was conducted using the most recent Demographic and Health Surveys (DHS). MDD data were available between 2019 and 2020 for three sub-Saharan African countries (Gambia, Liberia, and Rwanda). The study population included 5,832 children aged 6-23 months. A multivariable logistic regression model was developed to identify independent factors associated with meeting MDD.

Results

Overall, the weighted prevalence of children who met the MDD was 23.2% (95% CI: 21.7-24.8%), ranging from 8.6% in Liberia to 34.4% in Rwanda. Independent factors associated with meeting MDD were: age of the child (OR) = 1.96, 95% CI: 1.61, 2.39 for 12-17 months vs. 6-11 months], mothers from highest households' wealth status (OR = 1.86, 95% CI: 1.45-2.39) compared with the lowest, and mothers with secondary/higher education (OR = 1.69, 95% CI: 1.35-2.12) compared with those with no education. Mothers who were employed, had access to a radio, and those who visited a healthcare facility in the last 12 months were more likely to meet the MDD. There was no significant association between the child's sex and the odds of fulfilling the MDD.

Conclusions

There is substantial heterogeneity in the prevalence of MDD in these three sub-Saharan African countries. Lack of food availability or affordability may play a significant role in the low prevalence of MDD. The present analysis suggests that policies that will effectively increase the prevalence of meeting MDD should target poor households with appropriate materials or financial assistance and mothers with lower literacy. Public health interventions working with sectors such as education and radio stations to promote health education about the benefits of diverse diets is a critical step toward improving MDD in sub-Saharan Africa and preventing undernutrition.

A Randomized controlled trial of the Effect of intraVenous iron on Anaemia in Malawian Pregnant women (REVAMP): Statistical analysis plan

Background: Anaemia affects more than half of Africa’s pregnancies. Standard care, with oral iron tablets, often fails to achieve results, with compliance and gastrointestinal side-effects being a significant issue. In recent years, intravenous iron formulations have become safe, effective, and quick to administer, allowing the complete iron requirements of pregnancy to be provided in one 15-minute infusion. The Randomized controlled trial of the Effect of intraVenous iron on Anaemia in Malawian Pregnant women (REVAMP) will evaluate whether a modern intravenous iron formulation, ferric carboxymaltose (FCM), given once during the second trimester is effective and safe in improving maternal and neonatal outcomes for treatment of moderate to severe anaemia in sub-Saharan Africa.  

The objective was to publish the detailed statistical analysis plan for the REVAMP trial prior to unblinding the allocated treatments and performing the analysis.  

Methods: REVAMP is a multicentre, two-arm, open-label, parallel-group randomized control trial (RCT) in 862 pregnant women in their second trimester. The trial statistician developed the statistical analysis plan in consultation with the trial management team based on the protocol, data collection forms, and study outcomes available in the blinded study database.  

Results: The detailed statistical analysis plan will support the statistical analyses and reporting of the REVAMP trial after unblinding the treatment allocations.  

Conclusions: A statistical analysis plan allows for transparency as well as reproducibility of reporting and statistical analyses.

Geographical variations and determinants of iron and folic acid supplementation during pregnancy in Ethiopia: analysis of 2019 mini demographic and health survey

Background

One of the packages of critical antenatal care treatments for pregnant women includes iron and folic acid (Fe/FA) supplementation. Using recently available and nationwide representative survey data, this study aimed to determine the spatial patterns and drivers of Fe/FA supplementation during pregnancy.

Method

The data for this study was obtained from Ethiopia’s 2019 Mini Demographic and Health Survey (EMDHS). We used the Kid’s Record (KR) dataset, and a total weighted sample of 3926 reproductive-age women who gave birth within the previous 5 years was used as the study’s final sample size. To analyze the spatial distributions (geographic variation of Fe/FA supplementation) different statistical software like Excel, ArcGIS, and Stata 14 were used. A two-level multilevel binary logistic regression model was fitted to identify both individual and community-level factors associated with Fe/FA supplementation during pregnancy.

Result

This study found that there were significant geographical variations of iron and folic acid supplementation across Ethiopia, eastern and southern parts of the country were predicted to have low Fe/FA supplementation coverage. Advanced maternal age (AOR = 0.75: 95%CI: 0.59 0.96), resides in developing region (AOR = 0.57, 95%CI: 0.43 0.74), not attended formal education (AOR = 0.60, 95%CI: 0.39 0.92), middle (AOR = 1.51, 95%CI: 18 1.93) and rich wealth status (AOR = 1.48, 95%CI: 1.15 1.91), and four and above ANC visits (AOR = 4.35 95%CI: 3.64 5.21) were determinants of iron and folic acid supplementation among pregnant women.

Conclusion

Our research found that there were geographical variations across the country, with low coverage seen in Ethiopia’s eastern and southern regions. Iron and folic acid supplementation coverage were inadequate among pregnant women with low education, advanced maternal age, and those from underdeveloped countries. Conversely, increasing iron and folic acid uptake was associated with higher socioeconomic class and four or more ANC visits. The findings of this study highlight the importance of increasing maternal health care, such as iron and folic acid supplements, for underserved populations.

Community Preventive Health Education Intervention for Pediatric Iron-Deficiency Anemia in Rural Southeast Nigeria

Objectives

Iron-deficiency anemia (IDA) is a global cause of morbidity in children under five, particularly in sub-Saharan Africa. In southeast Nigeria, poor dietary intake and caregiver knowledge about childhood anemia are observed; however, there is no consensus on how to best prevent it. This study seeks to test the effectiveness of caregiver education on improving anemia knowledge and dietary prevention strategies and promoting sustainable lifestyle changes to reduce the prevalence of childhood IDA.

Study Design

A questionnaire was administered to the primary caregivers of 41 patients under age five with anemia in southeast Nigeria regarding socioeconomic status (SES), diet diversity, and risk factors for anemia. Caregivers were administered a preeducation questionnaire, poster education on anemia and iron-rich foods, and a posteducation questionnaire. All patients underwent a medical exam to confirm a diagnosis of anemia or anemia-related conditions.

Results

Ninety-five percent of patients had moderate diet diversity, but there was no correlation between diet diversity and SES. Barriers to healthier diets were associated with SES. Preeducation scores were not associated with caregivers' education levels; however, posteducation scores were significantly higher in university-educated than technical-trained caregivers. Caregiver-reported self-efficacy increased after the education program.

Conclusion

Caregivers' SES was associated with financial and knowledge barriers to a healthier diet but not diet diversity, suggesting that nutritional education could benefit all SES groups. Overall, the education program increased caregivers' anemia knowledge across educational levels. A community-based health education program could improve caregivers' anemia knowledge and self-efficacy in applying this information and potentially reduce this area's pediatric IDA.

Potential Role of African Fermented Indigenous Vegetables in Maternal and Child Nutrition in Sub-Saharan Africa

Hunger and malnutrition continue to affect Africa especially the vulnerable children and women in reproductive age. However, Africa has indigenous foods and associated traditional technologies that can contribute to alleviation of hunger, malnutrition, and communicable and noncommunicable diseases. The importance of African indigenous vegetables is undeniable, only that they are season-linked and considered as "food for poor" despite their high nutritional contents. The utilization of African indigenous vegetables (AIVs) is hindered by postharvest losses and antinutrients affecting the bioavailability of nutrients. In Africa, fermentation is among the oldest food processing technologies with long history of safe use. Apart from extending shelf life and improving food organoleptic properties, fermentation of African indigenous vegetables (AIVs) is known to improve food nutritional values such as proteins, minerals, vitamins, and other beneficial phytochemicals. It can also increase bioavailability of various vitamins, minerals, and phytochemicals and increase synthesis of vital blood pressure regulators thus protecting against cardiovascular diseases and cancer and further helping fight certain malnutrition deficiencies. Some lactic acid bacteria (LAB) involved in food fermentation are known to produce exopolysaccharides with cholesterol-lowering, immunomodulator, antioxidant, and anticancer properties. Fermented foods (vegetables) are superior in quality and safety since most microorganisms involved in fermentation are good starter cultures that can inhibit the growth of foodborne pathogens and detoxify harmful compounds in foods. Thus, fermented foods can boost growth and well-being in children and women due to their higher nutritional contents. Therefore, fermentation of AIVs can contribute to the attainment of food and nutrition security especially among women and children who rely on these vegetables as a staple source of micronutrients and income. These benefits have a positive impact on the implementation of the second sustainable development goals and African Union agenda 2063. This review is aimed at shedding light on the potential of African fermented indigenous vegetables in combating maternal and child malnutrition in Sub-Sahara Africa.

Pregnant women's decision-making capacity and adherence to iron supplementation in sub-Saharan Africa: a multi-country analysis of 25 countries

BACKGROUND

Anaemia and related complications during pregnancy is a global problem but more prevalent in sub-Sahara Africa (SSA). Women's decision-making power has significantly been linked with maternal health service utilization but there is inadequate evidence about adherence to iron supplementation. This study therefore assessed the association between household decision-making power and iron supplementation adherence among pregnant married women in 25 sub-Saharan African countries.

METHODS

We used data from the Demographic and Health Surveys (DHS) of 25 sub-Saharan African countries conducted between 2010 and 2019. Women's decision-making power was measured by three parameters; own health care, making large household purchases and visits to her family or relatives. The association between women's decision-making power and iron supplementation adherence was assessed using logistic regressions, adjusting for confounders. The results were presented as adjusted odds ratio (AOR) with 95% confidence intervals (CIs).

RESULTS

Approximately 65.4% of pregnant married women had made decisions either alone or with husband in all three decisions making parameters (i.e., own health care, making large household purchases, visits to her family or relatives). The rate of adherence to iron medication during pregnancy was 51.7% (95% CI; 48.5-54.9%). Adherence to iron supplementation was found to be higher among pregnant married women who had decision-making power (AOR = 1.46, 95% CI; 1.16-1.83), secondary education (AOR = 1.45, 95% CI; 1.05-2.00) and antenatal care visit (AOR = 2.77, 95% CI; 2.19-3.51). Wealth quintiles and religion were significantly associated with adherence to iron supplementation.

CONCLUSIONS

Adherence to iron supplementation is high among pregnant women in SSA. Decision making power, educational status and antenatal care visit were found to be significantly associated with adherence to these supplements. These findings highlight that there is a need to design interventions that enhance women's decision-making capacities, and empowering them through education to improve the coverage of antenatal iron supplementation.

A Randomized controlled trial of the Effect of intraVenous iron on Anaemia in Malawian Pregnant women (REVAMP): Statistical analysis plan

Background: Anaemia affects more than half of Africa’s pregnancies. Standard care, with oral iron tablets, often fails to achieve results, with compliance and gastrointestinal side-effects being a significant issue. In recent years, intravenous iron formulations have become safe, effective, and quick to administer, allowing the complete iron requirements of pregnancy to be provided in one 15-minute infusion. The Randomized controlled trial of the Effect of intraVenous iron on Anaemia in Malawian Pregnant women (REVAMP) will evaluate whether a modern intravenous iron formulation, ferric carboxymaltose (FCM), given once during the second trimester is effective and safe in improving maternal and neonatal outcomes for treatment of moderate to severe anaemia in sub-Saharan Africa.   The objective was to publish the detailed statistical analysis plan for the REVAMP trial prior to unblinding the allocated treatments and performing the analysis.   Methods: REVAMP is a multicentre, two-arm, open-label, parallel-group randomized control trial (RCT) in 862 pregnant women in their second trimester. The trial statistician developed the statistical analysis plan in consultation with the trial management team based on the protocol, data collection forms, and study outcomes available in the blinded study database.   Results: The detailed statistical analysis plan will support the statistical analyses and reporting of the REVAMP trial after unblinding the treatment allocations.   Conclusions: A statistical analysis plan allows for transparency as well as reproducibility of reporting and statistical analyses.

Uptake challenges of intermittent preventive malaria therapy among pregnant women and their health care providers in the Upper West Region of Ghana: A mixed-methods study

BACKGROUND

Malaria in pregnancy remains a major public health problem in endemic countries, especially in sub-Saharan Africa (SSA). Existing interventions such as intermittent preventive therapy in pregnancy (IPTp) using sulfadoxine-pyrimethamine (SP) are effective against placental malaria. However, low uptake of this intervention is a challenge in SSA. This study assessed factors affecting IPTp-SP uptake among pregnant women as well as their health care providers, including health system-related factors.

METHODS

From November 2018 until May 2019 a mixed-methods study was conducted in one urban and one rural district of the Upper West Region of Ghana. A multi-stage sampling technique was used to recruit 740 3rd trimester pregnant women and 74 health service providers from 37 antenatal care (ANC) facilities. Quantitative data was collected through a standard questionnaire from pregnant women and ANC service providers. Three focus group discussions (FGDs) were conducted in each district with pregnant women who had defaulted on their IPTp doses to collect information about the challenges in accessing IPTp-SP. The primary outcome was the uptake of IPTp-SP during antenatal care visits. In addition, the health care provider and health system-related factors on the administration of SP were assessed, as well as details of folic acid (FA) supplementation. Data were analysed using descriptive statistics and Poisson regression.

RESULTS

Responses from 697 pregnant women were analysed. Of these, 184 (26.4%) had taken the third dose of SP (SP3) in line with international guidelines. IPTp-SP uptake was low and significantly associated with the number of maternal ANC contacts and their gestational age at 1st ANC contact. Most pregnant women were regularly co-administered SP together with 5 mg of FA, in contrast to the international recommendations of 0.4 mg FA. The main challenges to IPTp-SP uptake were missed ANC contacts, knowledge deficiencies among pregnant women of the importance of IPTp, and frequent drug stock outs, which was confirmed both from the ANC providers as well as from the pregnant women. Further challenges reported were provider negligence/absenteeism, adverse drug reactions, and mobile residency of pregnant women.

CONCLUSIONS

The uptake of IPTp-SP in the study area is still very low, which is partly explained by frequent drug stock outs at health facilities, staff absenteeism, knowledge deficiencies among pregnant women, and missed ANC contacts. The high dosing of co-administered FA is against international recommendations. These observations need to be addressed by the national public health authorities.

Pre-conception serum ferritin concentrations are associated with metal concentrations in blood during pregnancy: A cohort study in Benin

BACKGROUND

Iron deficiency is a common nutritional deficiency that impacts maternal health and fetal development and is also associated with increased uptake of toxic metals. Women in sub-Saharan Africa are highly exposed to both iron deficiency and metals in the environment. As research on the developmental origins of health and disease increasingly shows impacts of pre-conception maternal health on pregnancy and fetal health, these environmental exposures are of concern.

OBJECTIVES

This study investigated the association between iron status pre-pregnancy and blood metal concentrations in the first trimester of pregnancy with potential implications for iron supplementation.

METHODS

Pre-conception and first trimester blood samples taken from 262 Beninese women were tested for serum ferritin, inflammation markers, manganese (Mn), cadmium (Cd), lead (Pb), copper, zinc, selenium, mercury and arsenic. Associations between serum ferritin adjusted for inflammation and metal concentrations were analyzed using multivariate linear regression.

RESULTS

Women with iron deficiency before conception (13%) were more likely to remain iron deficient in the first trimester (4%) (adjusted OR = 41.2, 95%CI 6.2; 275.0) even within the context of routine iron supplementation during pregnancy. Lower pre-pregnancy serum ferritin concentrations were significantly related to higher concentrations of Mn, Cd and Pb in the first trimester. Every 1% increase in serum ferritin concentration was associated with a 0.13% decrease in Mn (adjusted β = -0.13, 95%CI -0.18; -0.07), a 0.22% decrease in Cd (adjusted β = -0.22, 95%CI -0.28; -0.15) and a 0.06% decrease in Pb concentration (adjusted β = -0.06, 95%CI -0.12; -0.006).

DISCUSSION

These results suggest that increasing iron stores prior to pregnancy may prevent excessive uptake of toxic concentrations of the metals Mn, Cd and Pb and argue in favour of testing the effects of iron supplementation prior to pregnancy on metal concentrations.

Adherence status to iron with folic acid supplementation and associated factors among pregnant women receiving antenatal care at public health facilities in Northwest Ethiopia

Introduction:

Iron and folic acid deficiency is among the most frequent nutrient inadequacies in the world, affecting expected two billion people, and causing nearly a million deaths. The adherence rate to iron with folic acid supplements remains very low in Ethiopia. Therefore, this study aimed to assess adherence status to iron with folic acid supplementation and associated factors among pregnant women receiving antenatal care at public health facilities in Northwest Ethiopia.

Methods:

A facility-based cross-sectional study was conducted among pregnant women at public health facilities in the Debay Tilat Gen district from 27 February 2018 to 27 March 2018. Systematic random sampling was used to select pregnant women. Data were entered into Epidata version 3.1 and analysis was performed using SPSS version 20. Binary logistic regression was used to predict the association of the dependent variable with independent variables. Variables that showed association at a p-value of less than 0.25 in the bivariable analysis were a candidate for multivariable analysis. Finally, variables at a p-value less than 0.05 with corresponding 95% confidence interval declared statistically significant factors of iron with folic acid supplementations.

Results:

A total of 400 participants were included in the study. The mean (± standard deviation) age of study participants was 26.64 (±4.37 standard deviation) years. This study revealed that about 52.8% of pregnant women attending antenatal care clinics were adherent to iron with folic acid supplementation. Counseling on iron with folic acid supplementations (adjusted odd ratio = 2.53, 95% confidence interval = 1.37–4.66; p-value < 0.003), having current anemia (adjusted odd ratio = 4.21, 95% confidence interval = 1.77–9.94; p-value < 0.001), and good knowledge of iron with folic acid supplementations (adjusted odd ratio = 2.1, 95% confidence interval = 1.29–3.44; p-value < 0.003) showed statistically significant associations with adherence to iron with folic acid supplementation.

Conclusion:

This study revealed that more than half of pregnant women were adherent to iron with folic acid supplementation. Knowledge of iron with folic acid supplementations, current anemia, and being counseled were factors associated with pregnant women’s adherence to iron with folic acid supplementation. Therefore, counseling and awareness creation should be strengthened by health institutions.

Iron deficiency anaemia in sub-Saharan Africa: a review of current evidence and primary care recommendations for high-risk groups

The epidemiology of iron deficiency anaemia in sub-Saharan Africa differs from that in other parts of the world. The low-quality diets prevalent in this region are a poor source of iron, the population is frequently exposed to infection, and demographic characteristics result in a greater prevalence of people at high risk of iron deficiency anaemia than in other parts of the world. We herein review the causes, disease burden, and consequences of iron deficiency anaemia in the general population in this region, and current policies and interventions for its control. The current debate is dominated by concerns about the safety of iron interventions, namely regarding its effects on malaria and other infectious diseases. However, universal antenatal iron supplementation and delayed cord clamping are safe interventions and stand out for their potential to improve maternal and infant health. Effective infection control is a precondition to safe and efficacious iron interventions in children. Greater emphasis should be given to approaches aiming to reduce iron loss due to helminth infections and menstruation, alongside interventions to increase iron intake. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.

Factors Associated With Uptake of Iron Supplement During Pregnancy Among Women of Reproductive Age in Tanzania: an Analysis of Data From the 2015 to 2016 Tanzania Demographic and Health Survey and Malaria Indicators Survey

Background: Pregnant women are vulnerable to iron deficiency due to the fact that more iron is needed primarily to supply the growing fetus and placenta and to increase the maternal red cell mass. Little is known on the factors associated with uptake of iron supplement during pregnancy.

Methods: The study used data from the 2015 to 2016 Tanzania Demographic and Health Survey and Malaria Indicators Survey. A total of 6,924 women of active reproductive age from 15 to 49 were included in the analysis. Both univariate and multiple regression analyses were used to determine factors associated with uptake of iron supplement during pregnancy.

Results: Majority of the interviewed women 5,648 (81.6%) always took iron supplement during pregnancy, while a total of 1,276 (18.4%) women never took iron supplement during pregnancy. After controlling for confounders, the predictors for uptake of iron supplement during pregnancy were early antenatal booking (adjusted odds ratio, AOR = 1.603 at 95% CI = 1.362–1.887, p < 0.001); rural residence (AOR = 0.711 at 95% CI = 0.159–0.526, p = 0.007); wealth index [rich (AOR = 1.188 at 95% CI = 0.986–1.432, p = 0.07)]—poor was the reference population; level of education [primary education (AOR = 1.187 at 95% CI = 1.013–1.391, p = 0.034)]—no formal education was the reference population; parity [para 2 to 4 (AOR = 0.807 at 95% CI = 0.668–0.974, p = 0.026), para 5 and above (AOR = 0.75 at 95% CI = 0.592–0.95, p = 0.017)], para 1 was the reference population; zones [mainland rural (AOR = 0.593 at 95% CI = 0.389–0.905, p = 0.015) and Unguja Island AOR = 0.63 at 95% CI = 0.431–0.92, p = 0.017]—mainland urban was the reference population; and current working status [working (AOR = 0.807 at 95% CI = 0.687–0.949, p = 0.009)].

Conclusion: The study revealed that, despite free access to iron supplement during pregnancy, there are women who fail to access the supplement at least once throughout the pregnancy. The likelihood to fail to access iron supplement during pregnancy was common among pregnant women who initiated antenatal visits late, were from poor families, had no formal education, reside in rural settings, had high parity, were from mainland rural, and were in working status. Interventional studies are recommended in order to come up with effective strategies to increase the uptake of iron supplement during pregnancy.

Individual and community-level determinants of Iron-Folic Acid Intake for the recommended period among pregnant women in Ethiopia: A multilevel analysis

Background

Iron-folic acid (IFA) intake for the recommended period during pregnancy reduces the risk of anemia and congenital anomalies. However, IFA intake for the recommended period is still very low in low-income countries including Ethiopia. Thus, the aim of this study was to assess both individual-and community-level determinants of IFA intake for the recommended period among pregnant women in Ethiopia.

Methods

Data were retrieved from the Demographic and Health Survey program's official database website (http://dhsprogram.com). A two-stage stratified cluster sampling technique was employed to conduct the 2016 Ethiopian Demographic and Health Survey. A sample of 3088 pregnant women who had received at least one dose of IFA in Ethiopia were included in this study. A multivariable multilevel logistic regression analysis model was fitted to identify the determinants of IFA intake below the recommended period [< 90 days] during pregnancy. Akaike's Information Criterion (AIC) was used during the model selection procedure.

Results

This study revealed that 87.6% [95% CI; 86.3%, 88.6%] of the women took IFA below the recommended period during the index pregnancy. After adjusting for the covariates: living in rural areas [AOR = 1.74: 95% CI 1.37, 2.50], and women's illiterate proportion [AOR = 1.43: 95% CI 1.06, 1.70] were community level factors. Whereas, primary education level [AOR = 0.63: 95% CI 0.40, 0.78], poorer wealth index [AOR = 1.53: 95% CI 1.08, 3.09], 4 + antenatal care visits [AOR = 0.43: 95% CI 0.31, 0.69], and receive nutritional counseling during pregnancy [AOR = 0.63: 95% CI 0.37, 0.84] were the individual-level factors of IFA intake below the recommended period during pregnancy.

Conclusions

In this study, nearly nine out of ten pregnant women did not take IFA for the recommended period. Thus, promoting recommended ANC visits, enhancing the quality of nutritional counseling, strengthening the expansion of media, and educate rural women towards the importance of optimal intake of IFA during pregnancy. Besides, the policymakers should design essential strategies based on identified barriers to improve the IFA intake for the recommended period.

Determinant factors of poor adherence to iron supplementation among pregnant women in Ethiopia: A large population-based study

Introduction

Anemia during pregnancy increases the risk of premature delivery as well as maternal and child mortality. More than 40% and almost one-third of pregnant women are anemic worldwide and in Ethiopia respectively. Iron supplementation is important to prevent anemia during pregnancy in developing countries including Ethiopia. Despite this fact, it is at a substandard level in Ethiopia. Therefore, this study was conducted to identify the determinant factors of poor adherence to iron supplementation among pregnant women in Ethiopia.

Methods

A cross-sectional study was conducted based on the EDHS data for 2016 from two city administrations and nine regions of Ethiopia. A total of 3, 266 women were included. Bivariable and multivariable logistic regression analysis was employed. P-value < 0.05 and odds ratios were used to determine the significance and strength of association.

Results

Those pregnant women who had no mobile telephone [AOR; 0.79, 95% CI (0.65–0.95)], a history of cigarette smoking & alcohol use [AOR; 0.20, 95% CI (0.09–0.45)] and [AOR; 0.77, 95% CI (0.64–0.93)], and less than four antenatal care visits [AOR; 0.56, 95% CI (0.46, 0.68)] had higher odds of poor adherence.

Conclusion

Not having a mobile telephone, a history of smoking and alcohol use, and less than four antenatal care visits were determinant factors of poor adherence to iron supplementation. It is important to empower women, strengthen communication for behavioral change, and give attention to counseling pregnant women.

Adherence to iron and folic acid supplementation during pregnancy among postnatal mothers seeking maternal and child healthcare at Kakamega level 5 hospital in Kenya: a cross-sectional study

Background: Maternal anaemia is a public health problem worldwide, and its aetiology is linked to iron deficiency. The high nutrient demand during pregnancy exacerbates the condition. To meet the increased nutritional demand, supplementation of iron and folic acid (IFA) is key. The supplements are provided freely to pregnant women during antenatal visits at public health facilities, however, their uptake and adherence in Kenya remain unacceptably low. Methods: A hospital-based cross-sectional study involving 241 postnatal mothers seeking maternal and child healthcare (MCH) care at Kakamega level 5 hospital was conducted. Both quantitative and qualitative data were collected. Quantitative data were collected from 241 eligible postnatal mothers, while qualitative data were obtained through key informant interviews with community health volunteers and healthcare providers. Results: There was a moderate adherence to IFA supplementation (60.6%) during pregnancy among postnatal mothers seeking MCH care at Kakamega level 5 hospital. Some of the reasons for non-adherence stated by the respondents included; IFA related side effects (41.3%), forgetfulness (37.3%) and bad smell of the IFA supplements (10.3%). Higher IFA adherence was noted among the primigravida participants (OR=2.704; 95% CI: 1.262, 5.793; p=0.010) compared to multigravida participants, and those with a higher knowledge level of anaemia (OR=3.215; 95% CI: 1.346, 7.68; p=0.009) compared to their counterparts with low anaemia knowledge. Other factors that showed correlation with IFA adherence were: IFA education, pregnancy counselling before conception and the number of antenatal care visits attained. Conclusion: There is a moderate adherence to IFA supplementation during pregnancy among mothers seeking MCH at Kakamega level 5 hospital. The greatest impediments of IFA compliance during pregnancy are IFA side effects, forgetfulness and the bad smell of the IFA tablets. Therefore, providing IFA education to pregnant mothers incorporated with probable ways of managing the IFA side effects would contribute to IFA supplementation adherence.

Prevalence of iron and folic acid supplements consumption and associated factors among pregnant women in Eswatini: a multicenter cross-sectional study

Background

During pregnancy, nutritional requirements increase and if not met, pregnancy-related complications may manifest. To prevent these undesirable outcomes, the World Health Organization recommends daily oral iron and folic acid (IFA) supplementation as part of antenatal care. Despite this recommendation, the use of IFA supplements is still very low in several developing countries. Additionally, no prior information exists regarding the level of consumption of IFA in Eswatini. Thus, this study aimed to determine the prevalence of consumption of IFA supplements and to identify factors associated with the consumption of IFA supplements among pregnant women in Eswatini.

Methods

A cross-sectional questionnaire survey was conducted among 330 pregnant women aged ≥ 18 years in their third trimester in Eswatini. Participants were recruited from eight purposively selected healthcare facilities from July 2019 to October 2019. Good consumption was defined as consuming all or almost all IFA supplements throughout pregnancy.

Results

During the first trimester, 10.3 % of the participants consumed all or almost all IFA supplements. In the second and third trimesters, those who consumed all or almost all supplements were 37 and 39.7 %, respectively, for iron and 37.6 and 40.9 %, respectively, for folic acid. Barriers, including side effects, forgetfulness, safe previous pregnancies without IFA, others’ advice against consumption, IFA stock-outs, inability to meet transport costs, and inadequate supply of IFA tablets, contribute to low consumption of IFA. Multivariate logistic regression models showed that the barriers were inversely associated with good consumption of IFA supplements. Better knowledge and attitude toward IFA and older maternal age were positively associated with good consumption of IFA supplements.

Conclusions

Low consumption of IFA supplements in overall pregnancy is mainly owing to the late antenatal care attendance. Strategies such as establishing a preconception care unit and school-based provision of IFA may be helpful. It is evident that most women still lack knowledge, and some have negative attitudes about IFA supplements. Health education to raise awareness and emphasize the importance of starting antenatal care early as well as consuming supplements on time should be revisited and intensified. Multiple strategies such as including community health care workers for distributing IFA supplements, discussing with clients about the measures to reduce forgetfulness, advising ways to prevent and manage the side effects, providing subsidies to cover transport costs, and ensuring adequate supply of IFA supplements in facilities may need to be employed to reduce the identified barriers.

Self-management of iron and folic acid supplementation during pre-pregnancy, pregnancy and postnatal periods: a systematic review

Introduction

While the use of folic acid pre-pregnancy and iron and folic acid (IFA) during pregnancy and postnatal have been demonstrated to be effective and are recommended interventions by WHO, ensuring individuals adhere to the supplementation regimen can be a challenge. Self-care interventions that support an individual’s ability to promote their own health with or without the support of health workers could help promote the uptake and adherence to supplementation. This systematic review assessed the evidence around self-management of IFA or folic acid supplementation accessed over-the-counter during pre-pregnancy, pregnancy and postnatal periods.

Methods

Peer-reviewed studies were included if they compared self-management of IFA or folic acid supplementation with health worker-initiated supplement use on maternal and/or fetal and newborn health outcomes, end-users’ or health workers’ values and preferences, or cost and/or cost-effectiveness. We searched PubMed, CINAHL, LILACS and EMBASE for articles published through November 2020, hand-searched clinical trial registries, reviewed databases and contacted experts in the field. Abstract screening and full-text review were conducted independently by two reviewers.

Results

Overall, 2344 results were identified, and 28 studies were identified for full-text review. All studies were excluded, as they were not primary research, lacked the outcomes of interest, lacked specificity in supplement type, and/or lacked a comparison group.

Conclusion

No evidence was identified that distinguishes self-management of folic acid supplements pre-pregnancy and of IFA supplements during pregnancy and postnatal, highlighting a gap in our current understanding of self-care related to dietary supplementation in pregnancy. The findings of this review identify an area for further research to support the current movement towards self-care interventions as an added choice to help individuals more fully attain their reproductive health and rights.

Systematic review registration number

PROSPERO CRD42020205548

Direct assessment of body iron balance in women with and without iron supplementation using a long-term isotope dilution method in Benin and Switzerland

BACKGROUND

Long-term isotopic dilution measurements of body iron may allow quantification of basal body iron balance and iron gains during an iron intervention with higher precision and accuracy than conventional iron indices.

OBJECTIVES

We compared body iron balance before, during, and after oral iron supplementation in women in Benin and in Switzerland.

METHODS

In prospective studies, Beninese (n = 11) and Swiss (n = 10) women previously labeled with stable iron isotopes were followed preintervention for 90-120 d, then received 50-mg iron daily for 90-120 d and were followed postintervention for 90-120 d. We used changes in blood isotopic composition to calculate iron absorption (Feabs), iron loss (Feloss), and net iron balance (Fegain).

RESULTS

Compliance with supplementation was >90%. In Benin, during the preintervention, intervention, and postintervention periods, Fe means ± SDs were as follows: 1) Feabs: 0.92 ± 1.05, 3.75 ± 2.07, and 0.90 ± 0.93 mg/d; 2) Feloss: 1.46 ± 1.95, 1.58 ± 1.57, and 1.84 ± 1.61 mg/d; and 3) Fegain: -0.55 ± 1.56 mg/d, 2.17 ± 1.81 mg/d, and -0.94 ± 1.13 mg/d. In Switzerland, the corresponding values were: 1) 1.51 ± 0.37, 4.09 ± 1.52, and 0.97 ± 0.41 mg/d; 2) 0.76 ± 1.37, 2.54 ± 1.43, and 2.08 ± 1.05 mg/d; and 3) 0.75 ± 1.37, 1.55 ± 1.75, and -1.11 ± 1.06 mg/d. Inflammation was low in both settings, and isotopically calculated iron balance was comparable to that calculated from changes in conventional iron indices.

CONCLUSION

Without iron supplementation, Beninese women had lower long-term dietary iron absorption and higher iron losses in the preintervention period than Swiss women. During iron supplementation, both groups had high iron absorption and similar iron gains. However, there was a 3-fold increase in iron losses in the Swiss women during the supplementation and postintervention period compared with the preintervention period. Body iron isotope dilution is a promising new method for quantifying long-term body iron balance and for assessing the impact of iron interventions. The studies were registered at clinicaltrials.gov as NCT02979080 and NCT02979132, respectively.

Effect of direct monitoring by family members and counseling by health professionals on iron-folic acid supplementation: A cross-sectional study among pregnant women in Puducherry, India

BACKGROUND:

The prevalence of iron-deficiency anemia in pregnant Indian women is reportedly quite high. Despite the sustained efforts of the current national control program and undisputed efficacy of iron-folic acid supplementation (IFAS), the onslaught of anemia has not been curtailed, probably as a result of noncompliance to IFAS. The objective of this study was to assess the effect of direct monitoring of pregnant women by family members, counseling by health professionals, and other variables on adherence to IFAS in Puducherry, India.

MATERIALS AND METHODS:

A cross-sectional study was conducted among 250 pregnant women visiting Outpatient Clinic, Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry. Missing ≥2 doses of IFAS in the preceding 7 days was considered as nonadherence. The Pearson Chi-square test was applied to identify the association between the different variables. Bivariate and multivariate logistic regressions revealed variables affecting adherence.

RESULTS:

Around 34.4% of respondents reported nonadherence to IFAS. Direct monitoring by family members (Adjusted Odds Ratio [aOR] = 7.04; P < 0.001), counseling by health professionals (aOR = 2.97; P = 0.002), and improvement in hemoglobin (Hb) levels (aOR = 2.4; P = 0.01) were associated with better adherence. Vomiting, abdominal pain, and diarrhea were common ADRs. The distance to hospital, improvement in Hb levels, counseling by health professionals, and direct monitoring by family members significantly reduced the odds of ADRs.

CONCLUSION:

Direct monitoring of intake by family members and counseling by health professionals improved adherence to IFAS. Further in-depth formative research studies are recommended for strategies to improve adherence to IFAS in the vulnerable pregnant population of Puducherry and streamline the implementation of anemia national control program in a specific context.

Adherence to iron and folic acid supplementation during pregnancy among postnatal mothers seeking maternal and child healthcare at Kakamega level 5 hospital in Kenya: a cross-sectional study

Background: Maternal anaemia is a public health problem worldwide, and its aetiology is linked to iron deficiency. The high nutrient demand during pregnancy exacerbates the condition. To meet the increased nutritional demand, supplementation of iron and folic acid (IFA) is key. The supplements are provided freely to pregnant women during antenatal visits at public health facilities, however, their uptake and adherence in Kenya remain unacceptably low. Methods: A hospital-based cross-sectional study involving 241 postnatal mothers seeking maternal and child healthcare (MCH) care at Kakamega level 5 hospital was conducted. Both quantitative and qualitative data were collected. Quantitative data were collected from 241 eligible postnatal mothers, while qualitative data were obtained through key informant interviews with community health volunteers and healthcare providers. Results: There was a moderate adherence to IFA supplementation (60.6%) during pregnancy among postnatal mothers seeking MCH care at Kakamega level 5 hospital. Some of the reasons for non-adherence stated by the respondents included; IFA related side effects (41.3%), forgetfulness (37.3%) and bad smell of the IFA supplements (10.3%). Higher IFA adherence was noted among the primigravida participants (OR=2.704; 95% CI: 1.262, 5.793; p=0.010) compared to multigravida participants, and those with a higher knowledge level of anaemia (OR=3.215; 95% CI: 1.346, 7.68; p=0.009) compared to their counterparts with low anaemia knowledge. Other factors that showed correlation with IFA adherence were: IFA education, pregnancy counselling before conception and the number of antenatal care visits attained. Conclusion: There is a moderate adherence to IFA supplementation during pregnancy among mothers seeking MCH at Kakamega level 5 hospital. The greatest impediments of IFA compliance during pregnancy are IFA side effects, forgetfulness and the bad smell of the IFA tablets. Therefore, providing IFA education to pregnant mothers incorporated with probable ways of managing the IFA side effects would contribute to IFA supplementation adherence.

Prevalence and determinants of cervical cancer screening in five sub-Saharan African countries: A population-based study

BACKGROUND

Cervical cancer is the fourth most common cancer among women worldwide, with an estimate of 570,000 new cases and about 311,000 deaths annually. Low-resource countries, including those in sub-Saharan Africa, have the highest-burden with an estimate of 84 % of all cervical cancers. This study examines the prevalence and socio-demographic-economic factors associated with cervical cancer screening in sub-Saharan Africa.

METHODS

A weighted population-based cross-sectional study using Demographic and Health Surveys data. We used available data on cervical cancer screening between 2011 and 2018 from the Demographic and Health Surveys for five sub-Saharan African countries (Benin, Ivory Coast, Kenya, Namibia, and Zimbabwe). The study population included women of childbearing age, 21-49 years (n = 28,976). We fit a multivariable Poisson regression model to identify independent factors associated with cervical cancer screening.

RESULTS

The overall weighted prevalence of cervical cancer screening was 19.0 % (95 % CI: 18.5 %-19.5 %) ranging from 0.7 % in Benin to 45.9 % in Namibia. Independent determinants of cervical cancer screening were: older age (40-49 years) adjusted prevalence ratio (aPR) = 1.77 (95 % CI: 1.64, 1.90) compared with younger age (21-29 years), secondary/higher education (aPR = 1.51, 95 CI: 1.28-1.79) compared with no education, health insurance (aPR = 1.53, 95 % CI: 1.44-1.61) compared with no insurance, and highest socioeconomic status (aPR = 1.39, 95 % CI: 1.26-1.52) compared with lowest.

CONCLUSION

The prevalence of cervical cancer screening is substantially low in sub-Saharan Africa countries and shows a high degree of between-country variation. Interventions aimed at increasing the uptake of cervical cancer screening in sub-Saharan Africa are critically needed.

Global, regional and national epidemiology and prevalence of child stunting, wasting and underweight in low- and middle-income countries, 2006-2018

In 2016, undernutrition, as manifested in childhood stunting, wasting, and underweight were estimated to cause over 1.0 million deaths, 3.9% of years of life lost, and 3.8% of disability-adjusted life years globally. The objective of this study is to estimate the prevalence of undernutrition in low- and middle-income countries (LMICs) using the 2006-2018 cross-sectional nationally representative demographic and health surveys (DHS) data and to explore the sources of regional variations. Anthropometric measurements of children 0-59 months of age from DHS in 62 LMICs worldwide were used. Complete information was available for height-for-age (n = 624,734), weight-for-height (n = 625,230) and weight-for-age (n = 626,130). Random-effects models were fit to estimate the pooled prevalence of stunting, wasting, and underweight. Sources of heterogeneity in the prevalence estimates were explored through subgroup meta-analyses and meta-regression using generalized linear mixed-effects models. Human development index (a country-specific composite index based on life expectancy, literacy, access to education and per capita gross domestic product) and the United Nations region were explored as potential sources of variation in undernutrition. The overall prevalence was 29.1% (95% CI 26.7%, 31.6%) for stunting, 6.3% (95% CI 4.6%, 8.2%) for wasting, and 13.7% (95% CI 10.9%, 16.9%) for underweight. Subgroup analyses suggested that Western Africa, Southern Asia, and Southeastern Asia had a substantially higher estimated prevalence of undernutrition than global average estimates. In multivariable meta-regression, a combination of human development index and United Nations region (a proxy for geographical variation) explained 54%, 56%, and 66% of the variation in stunting, wasting, and underweight prevalence, respectively. Our findings demonstrate that regional, subregional, and country disparities in undernutrition remain, and the residual gaps to close towards achieving the second sustainable development goal-ending undernutrition by 2030.

Adherence to Iron with Folic Acid Supplementation Among Pregnant Women Attending Antenatal Care in Public Health Centers in Simada District, Northwest Ethiopia: Using Health Belief Model Perspective

INTRODUCTION

Even though the World Health Organization recommends daily oral iron with folic acid (IFA) supplementation as part of the antenatal care to prevent anemia, still the utilization remains low in Sub-Saharan Africa, particularly in Ethiopia. Therefore, the aim of this study was to assess the magnitude of adherence of iron with folic acid supplementation and associated factors among pregnant women who were attending antenatal care (ANC).

METHODS

A facility-based cross-sectional study was conducted from February 24 to March 23, 2020. Four hundred and twenty-two participants were selected using systematic random sampling technique. Data were collected using a structured questionnaire through face-to-face interview. Data were entered and analyzed using EpiData and SPSS version 20.0, respectively. Bivariate and multivariable logistic regression analyses were done to identify associated factors of adherence, and P<0.05 was used as cutoff to determine statistical significance at multivariable logistics regressions.

RESULTS

In this study, 414 (98%) pregnant women participated. The mean age of the respondents was 28.69 ±SD 5.49 years. The magnitude of adherence of IFA supplementation among pregnant women was 67.6% (95%CI: 63.3-72.5). Pregnant women who had a past history of preterm delivery (AOR=3.70; 95%CI: 1.46-9.37), counseling on IFA supplementation (AOR=2.28; 95%CI: 1.15-4.53), high perceived benefit (AOR=2.72; 95%CI: 1.25-5.90) and high self-efficacy (AOR=2.91; 95%CI: 1.40-6.04) were found to be significant associated factors of adherence to IFA supplementation.

CONCLUSION

In this study, adherence to IFA supplementation among pregnant women is relatively high. Past history of preterm delivery, counseling on IFA supplementation, perceived benefit and self-efficiency had association with adherence to IFA supplementation. Proper counseling and health education should be given to pregnant women to increase their adherence.

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.