COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF MIDWIFERY
ADHERENCE OF IRON FOLATE SUPPLEMENT AND
ASSOCIATED FACTORS AMONG PREGNANT WOMEN
ATTENDING ANC AT WILDIA COMPREHENSIVE
SPECILEZED HOSPITAL, NORTH WOLLO, NORTH EAST
ETHIOPIA, 2022.

INVESTIGATORS; 1. WUDIE SEMAHEGNE (BSC student)

2, MEKOYET ARAGEW (BSC student)

ADVISOR: 1.Sr. WAGAYE SHUMET (BSc, MSc in clinical midwifery)

2. SOLOMON M. (BSC, MSC).

A Research to be submitted to Woldia University College of Health Sciences, Department of

Midwifery in partial fulfillment of the requirements for the completion of BSC degree in
Midwifery.

Ethiopia

2023
Acknowledgement

First of for, we wish to extend our deepest thanks to our advisor Sr. WAGAYE SHUMENT.
(BSc, MSc) for her invaluable advice, suggestions and continued technical support through the
course of the study. Our respect and acknowledgement is also forwarded to Mr. SOLOMON M.
(BSc, MSc) who has helped us a lot in understanding the course for this Research Paper. Then,
we would like thank Woldia University College of health science and department of midwifery
for giving us this chance to conduct this research. I addition we would like to thank WCSH for
giving permission to collect data. We would like to thank the participants’ for their voluntariness.

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Acronyms and abbreviations
ANC Antenatal care

CHW Community Health Worker

EDHS Ethiopia Demographic Health Service.

IDDS Individual Dietary Diversity Score.

IF Iron &folate.

IDA Iron Deficiency Anemia.

INACG International Nutritional Anemia Consultative Group.

NGOs Non-Governmental Organizations.

NHANES National Health and Nutrition Examination Survey.

SPSS Statistical Package for Social Sciences.

WHO World Health Organization.

WCSH Woldia Comprehensive Specialized Hospital

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 Summary
Background: Anemia is the leading causes of morbidity and mortality among pregnant women.
In Ethiopia, higher proportions of pregnant women are anemic. Iron folate supplementation has
been a major strategy in low-income and middle-income countries where micronutrient
deficiencies are common to reduce iron deficiency anemia in pregnancy.

Objective: To assess the adherence and factors associated to iron and folic acid supplements
among pregnant women attending antenatal care at Woldia Comprehensive Specialized hospital,
North east Ethiopia, 22/2023

Method: Institution based cross-sectional study was conducted at Woldia Comprehensive

Specialized Hospital, North Wollo, North east Ethiopia, 2022. Data will be collected using
pretested interview administered questionnaire. The collected data will be checked for
completeness and accuracy and will be analyzed by using SPSS. Descriptive analysis will be
performed to know frequency and percentage. The analyzed data will be presented using tables,
pi-charts and bar graph

Result: The proportion of mother’s adherent to iron and folic acid supplements was 46.08%.
The variables that significantly associate with iron folate adherence were had no formal
education [AOR =0.233, 95% CI: (0.082, 0.664)], poor knowledge about anemia [AOR= 2.089,
95% CI: (0.972, 4.493), developing any other health problem during current pregnancy
[AOR=0.439, 95% CI: (0.2o4, 0.945)] mothers were less likely adherent to the supplement
compared with their counterparts.

Conclusion and Recommendation: In this study nearly half pregnant mothers had
adherence for iron folate.

Maternal educational status, knowledge about anemia, exposure to information, experiencing of

health problems were associated with adherence behavior. This indicates that improving
dissemination of information about the supplements and designing a reminder mechanism was
needed to improve the adherence status of mothers to the supplement.

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 Key word; adherence, iron and foliate supplement, pregnant mother, associated factor, anti-
natal care, Ethiopia.

Table of Contents
Acknowledgement.........................................................................................................................................ii

Acronyms and abbreviations....................................................................................................................iii

Abstract.........................................................................................................................................................iv

1-Introduction................................................................................................................................................1

1.1 Back Ground of the study....................................................................................................................1

1.2 Statement of the Problem.....................................................................................................................2

1.3 Significance of the study......................................................................................................................3

2. LITERATURE REVIEW..........................................................................................................................4

2.1 Adherence of iron folate supplement...................................................................................................4

2.3 Factor associated with adherence.........................................................................................................5

2.3.1 Socio demographic factor.............................................................................................................5

2.3.2 Supplement and related factor......................................................................................................6

2.3.3 Obstetric related Factor.................................................................................................................6

2.3.4 Health service factor and knowledge about IFA...........................................................................6

2.3.5Physical attribute and related factor..........................................................................................7

3 OBJECTIVE...............................................................................................................................................9

3.1 GENERAL OBJECTIVE..................................................................................................................9

3.2 SPECIFIC OBJECTIVES:...............................................................................................................9

4. Methods and Materials...............................................................................................................................9

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4.1. Study Area and Period.....................................................................................................................9

4.2. STUDY DESIGN...............................................................................................................................9

4.3. SOURCE OF POPULATION..........................................................................................................9

4.4. Study population...............................................................................................................................9

4.5 Study unit..........................................................................................................................................10

4.6 Sampling unit...................................................................................................................................10

4.7INCLUSION AND EXCLUSION CRITERI.................................................................................10

4.7.1 Inclusion criteria...........................................................................................................................10

4.7.2 Exclusion criteria......................................................................................................................10

4.8 SAMPL SIZE DETERMINATON.................................................................................................10

4.9 Sampling technique..........................................................................................................................11

4.8 Data collection instrument..............................................................................................................11

4.9 Data collection procedure................................................................................................................11

4.10 Data quality assurance..................................................................................................................11

4.12 data processing and analysis.........................................................................................................11

4.13 Dependent and independent Variable..........................................................................................12

4.13.1 Dependent variable.................................................................................................................12

4.13.2 Independent variables:...........................................................................................................12

4.13.2.1 Socio-demographic factors:..................................................................................................12

4.13.2.3 Health care and system related factors:...............................................................................12

4.14 ETHICAL CONSIDERATION....................................................................................................13

4.15 OPERATIONAL DEFINITION OF VARIABLES....................................................................13

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 4.15.1 Knowledge to anemia:............................................................................................................13

4.15.2 Knowledge to benefits of Iron/folic acid:..............................................................................13

4.15.3 Antenatal services:..................................................................................................................13

4.15.4 Adherence:...............................................................................................................................13

4.15.5 Non adherence:........................................................................................................................13

5. RESULTS................................................................................................................................................14

5.1 Socio-demographic characteristics.................................................................................................14

5.2 Pregnancy and Obstetric related characteristic of respondent...........................................................16

5.3 Respondents knowledge of anemia and benefit of Iron and foliate supplements..............................17

5.4 Health care Service related characteristics........................................................................................18

5.5 Adherence level of women to iron/foliate supplementation during pregnancy.........................19

5.6 Reasons for not taking the supplement......................................................................................20

5.7 Determinants factors on adherence of iron and folate supplements among pregnant women 20

6. DISCUSSION..........................................................................................................................................23

7. Conclusion...............................................................................................................................................24

8. RECOMENDATION...............................................................................................................................24

Reference.....................................................................................................................................................26

ANNEXES 1................................................................................................................................................29

ENGLISH VERSION CONSENT & QUESTIONNAIRE.........................................................................29

ANNEX 2.....................................................................................................................................................37

Amharic version questionaries.....................................................................................................................37

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List of figures and list of table

Figure 1: Conceptual framwork…………………………………………………………………………9

Figure 2: Age of responding pregnant women attending ANC at WCSH, 2023………………………….16

Figure 3: Adherence level of pregnant women attending ANC at WCSH, 2023………………………19

Table 1: Socio-demographic and economic characteristics of respondent of pregnant...............................14
Table 2: pregnancy and obstetrics related characteristic of respondent at WCSH, North East Ethiopia. (n=306).
............................................................................................................................................................................17
Table 3: Respondents knowledge on anemia and benefit of IFA Supplement at WCSH, North East Ethiopia.. 18
Table 4: Service related characteristics, at WCSH, North East Ethiopia. (n=306).............................................18

Table 5: level of adherence related characteristics, at WCSH, North West Ethiopia…………………..19

Table 6: Association between factors and adherence on pregnant women attending ANC at WCSH,
2023…………………………………………………………………………………………………………
……………………………………………20

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1. Introduction

1.1Back Ground of the study

Plasma volume increases progressively throughout normal pregnancy of this 50% increase
occurs by 34 weeks’ gestation and is proportional to the birth weight of the baby(1). Because the
expansion in plasma volume is greater than the increase in red blood cell mass, there is a fall in
hemoglobin concentration, hematocrit and red blood cell count. Despite this haemodilution, there
is usually no change in mean corpuscular volume (MCV) or mean corpuscular hemoglobin
concentration (MCHC)(2).

Pregnancy causes a two- to three-fold increase in the requirement for iron, not only for
hemoglobin synthesis but also for the fetus and the production of certain enzymes(2). There is a
10- to 20-fold increase in folate requirements and a two-fold increase in the requirement for
vitamin B12(3)

World health organization recommends iron and folic acid supplementation for pregnant women,
starting early in pregnancy, At a daily dose of 30–60 mg of elemental iron plus 400 μg of folic
acid, for 180 days(4). As this has been shown to reduce the risk of low birth weight, maternal
anemia and iron deficiency(5). In settings where anemia in pregnant women are a severe public
health problem a daily dose of 60 mg of elemental iron is preferred over a lower dose (6) .
Anemia is a global public health problem affecting both developing and developed countries
with major consequences for human health(7).Half of anemia burden is assumed to be due to
iron deficiency(8).It is a reduction of hemoglobin concentration less 11 g/dl. Iron deficiency
anemia is the most common nutritional disorder affecting two billion people worldwide(9) .
Based on evidence from iron supplementation trials, it was estimated that, on average, 50% of
anemia globally is caused by iron deficiency (10). Pregnant women are at especially high risk of
iron deficiency and anemia because of significantly increased iron requirements during
pregnancy. Iron supplementation has been a major strategy in low-income and middle-income
countries where micronutrient deficiencies are common to reduce iron deficiency anemia in
pregnancy(11).

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Globally 41.8% almost half of all pregnant women are anemic with the highest proportion
affected in developing countries(12). The prevalence of anemia among pregnant women in
developed country is 18% in average, which is significantly lower than the average 56% in
developing countries(13). The actual prevalence of anemia in pregnant women in Africa and
Asia is estimated to be 57.1% and 48.2% while that of America and Europe is 24.1% and 25.1%
respectively(12). Currently seventeen percent of Ethiopian women age 15-49 are anemic with the
highest proportion of pregnant women (22%) than breastfeeding (19 %) and neither pregnant nor
breastfeeding women (15 %). Anemia prevalence also varies by urban and rural residence; a
higher proportion of women in rural areas are anemic (18 %) than those in urban areas (11 %)
(14).

The 2011 EDHS revealed that maternal nutritional status is poor in many respects in Ethiopia.
Out of 17% of anemic women, 13% of them having mild anemia where hemoglobin level range
between 10 g/dl and 10.9 g/dl, 3% having moderate anemia where Hgb level range between 7
g/dl and 9.9 g/dl, and 1% having severe anemia where Hgb level is <7 g/dl(15). Ethiopia, like
most sub-Saharan Africa countries, has a national policy to prevent and treat anemia in
pregnancy. This includes the provision of ferrous sulfate and folic acid to all pregnant
women(16).

2
1.2 Statement of the Problem

About 18% of maternal mortality in low- and middle-income countries almost 120,000 deaths is
attributable to iron deficiency(17) . Anemia is cause for loss of one million lives each year,
associated with increased child and maternal mortality, stillbirths, low-birth weight and
premature babies. It is one of the world's leading causes of disability and cause mental
retardation and decreased work performance(18) .

Iron deficiency anemia occurs when iron stores are exhausted and the supply of iron to the
tissues is compromised. IDA in pregnant women is a sever stage of iron deficiency in which
hemoglobin (Hgb) and hematocrit (Hct) level falls below 11g/dl and 33% respectively(19).Even
though interventions are often designed in both national and international level to prevent the
decrease in hemoglobin concentration and iron stores associated with pregnancy, the major
obstacle to iron supplementation is adherence with treatment. This is often due to its side-effects,
forgetfulness, women’s lack of awareness, mothers knowledge to anemia and knowledge of iron
folate supplement(20) .

According to the Demographic Health Survey of 2011, adherence to iron/folate supplements by

pregnant women in Ethiopian is very low. Nationally only 0.4% of the pregnant women take Iron
supplements more than 90 days of the recommended 180 days. In Oromiya region 87.9% of
pregnant women do not take any iron tablets or syrup during pregnancy, while 10.8% take for
less than 60 days, 0.4% takes for 60-89 days and only 0.3% take for 90 days or more(21) . The
aim of this study is to determine adherence rate and associated factors to iron and folic acid
supplementation among pregnant women attending antenatal care(22).

3
1.3 Significance of the study

Findings from this study will give a highlight into the adherence rate and factors that determine
iron and folic acid supplementation among pregnant women. This will be helpful for policy
maker in the planning and implementation of intervention activities to improve the antenatal
adherence to IFA supplement service in the town. In addition, it will benefit for health care
provider to give the appropriate supplementation for pregnant women in the right time and
follow compliance. It will play very great roll for pregnant women in awareness creation and
sticking to the right dose supplement as standard national recommendation.

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1.4 LITERATURE REVIEW

1.4.1 Adherence of iron folate supplement

Cross-sectional data from India’s third National Family Health Survey used to examine the
association between adequately diversified dietary intake, iron and folic acid supplementation
during pregnancy and symptoms suggestive of Preeclampsia or eclampsia in Indian women. The
likelihood of reporting Preeclampsia or eclampsia symptoms was also 36% lower among those
mothers who consumed iron and folic acid supplementation for at least 90 days during their last
pregnancy(23) . Subsequent analysis in Indonesia showed that 20% of early neonatal deaths in
Indonesia could be attributed to a lack of iron and folic acid supplementation during
pregnancy(24) . The health issues associated with, the most common micronutrient, Iron
deficiency anemia is reduced cognitive capability(25) .reduced physical capacity and
productivity, increased maternal mortality, complications with childbirth, and increased infant
mortality(26) . Using iron-folic acid was protective against anemia and LBW infants (27).

A cross-sectional study done in Malawi shows that 96.6% of the women had awareness about
anemia, with at least two thirds knowing its causes, ways of prevention, and treatment. As
expected, health facilities are the primary source of iron supplements (97.1%)(28) . Study in
Kathmandu University shows that among 53 participants overall prevalence of anemia with
hemoglobin less than 11 gm./dl was 37.74%. The prevalence of IDA among pregnant women
was 24.52% and the prevalence of IDA among anemic pregnant women was 65%(17) .

The study in Khartoum Hospital, Sudan, to assess the rates of iron and folic supplementation and
the associated factors during pregnancy and the effects of taking iron-folic acid supplementation
on rates of maternal anemia and low birth weight (LBW)7 infants. Revealed that of 856 women,
enrolled and answered a questionnaire, 788 (92.1%) used iron-folic acid supplementation during
pregnancy and 65.4% used folic acid(29) .

The study was conducted in the 270 clustered villages drawn from 9 administrative regions in
Ethiopia shows the prevalence rate of clinical anemia, anemia, ID (iron deficiency) and IDA
were 11.3%, 30.4%, 49.7% and 17.0% respectively. The majority of anemic women were in the
category of mild (19.3%) to moderate (10.3%) and severe anemia was 0.9%.

5
A significantly higher proportion of clinical anemia, anemia (Hgb), ID and IDA was observed in
afar signifying distinct regional variation. The most affected age groups were those between 36-
49 years(30) .

A cross sectional study conducted in eight rural districts in SNNP, Ethiopia to assess the
coverage, compliance and factors associated with the use of antenatal iron supplement. Among
women who gave birth in preceding year, 35.4% where given prescribed antenatal iron
supplement and the average level of compliance was 74.9% (12).

A cross-sectional study design conducted to assess the prevalence and associated risk factor of
maternal anemia from April to May, 2014 in Nekemte Referral Hospital, Western

Ethiopia. Out of 286 pregnant women attending antenatal clinic 29% were anemic out of these
majorities were mild types 72.20%(31) .According to the EMDHS of 2014 among women with a
live birth in the five years preceding the survey, 34 percent took iron tablets during their last
pregnancy. Consumption of iron tablets by pregnant women doubled from 15 percent in 2011 to
34 percent in 2014. The percentage of pregnant women who took iron tablet during their last
birth in Oromia region were 24.7% very low and 61% in Tigray being the highest(32) .

A cross sectional household survey conducted to determine the prevalence of use of antenatal
IFA supplements, and the socio-demographic factors associated with the non-use of antenatal
IFA supplements in 14 project districts across Pakistan shows that Of 6,266 women interviewed,
2,400 reported taking IAF supplements during their last pregnancy(33).

A descriptive cross-sectional study conducted to assess the maternal, knowledge and institutional
factors that predict 90+ days (optimum) iron-folate supplementation among pregnant women in a
rural set-up in Eastern Kenya from 352 mothers of under-five years old children attending 7
health facilities Using a standard questionnaire, mothers recalled the number of days they had
ingested iron-folate supplements in their latest pregnancies. The overall prevalence of optimum
supplementation (90+ days) during latest pregnancies was 18.3% and on average the study
mothers were supplemented for ~38 days during the antenatal period(34) .

The study conducted in Malawi found that 22.5%, 29% and 33.8% of women from the Central,
Northern and Southern regions, respectively reported taking the supplements for 8 one month

6
only during their most recent pregnancy. Overall, about 9% reported taking the supplements
throughout pregnancy (35).

A cross-sectional, community-based study conducted to assess the proportion of pregnant

mothers consumes the IFA tablets and the factors determine Compliance in rural area of India on
50 antenatal mothers by multistage sampling technique. Ultimately 50 were participated amongst
the 57 eligible antenatal mothers with a non-responder rate 12.28%. The IFA tablet was
adequately and regularly consumed by 31 (62%) mothers among the study population(36) . The
study included 190 pregnant women seeking ante-natal care in tertiary health centers in the
Mangalore city in south India. To estimate the compliance for IFA tablets among pregnant
women and to study the social factors influencing it considering Missing >2 doses consecutively
were non-compliance. Shows that overall, compliance with IFA tablets was 64.7%. Compliance
increased with the increase in age, birth order and single daily dose(37) . According to the
Demographic Health Survey of 2011, adherence to iron/folate supplements by pregnant women
in Ethiopian is very low. Nationally only 0.4% of the pregnant women take Iron supplements
more than 90 days of the recommended 180 days. In Oromia region 87.9% of pregnant women
do not take any iron tablets or syrup during pregnancy, while 10.8% take for less than 60 days,
0.4% takes for 60-89 days and only 0.3% take for 90 days or more(38).

A cross sectional study conducted in eight rural districts in SNNP, Ethiopia to assess the
coverage, compliance and factors associated with the use of prenatal iron supplements. Suggest
that among 414 pregnant women asked structured questionnaire that gave birth in the preceding
year, 35.4% were given/prescribed prenatal iron supplement during the index pregnancy and
among pregnant women who were given/prescribed supplements, the average level of
compliance was 74.9%(17) .

Community based cross sectional study design employed in Mecha district from June 25 -July
15/2013. The study was done to investigate factors associated with compliance of prenatal iron
folate supplementation. A total of 628 women who gave birth twelve months 9 before the survey
were enrolled. The study revealed that only 20.4% of participants were compliant with iron
foliate supplementation(39) .

7
A cross sectional study in urban slam, India shows that compliance to iron pills increases with
increase in level of education, early registration, increase in number of antenatal visits and
knowledge of hemoglobin status and iron pill dose. Women from nuclear family with less
number of children have better compliance. The overall compliance was found to be61.7%.
Forgetfulness, ignorance toward self-health care and to visit health facility, big size of tablets and
palatability, and frustration to take daily pills appears to main causes of noncompliance(17) .

8
1.5 Factor associated with adherence

1.5.1 Socio demographic factor

Socio-demographic factors significantly associated with the non-use of antenatal IF supplements

were maternal age 45 years and above, no maternal education, no paternal education, belonging
to the lowest household wealth index quartile, and no use of antenatal care (ANC) services(17) .
Specifically maternal employment was the factors associated with folic acid compliance (40).
The consumption was maximum (100%) in socio economic Class V, whereas class I is
practically nil(41) . On the other hand, Factors significantly associated with consumption of 100
tablets, after simple logistic regression, were education, parity, timing of ante-natal registration
and number of ante-natal care visits to any facility. On multiple logistic regression, applying
enter method and considering all variables, only prime parity and elder age were found to be the
predictors for 100 iron and folic acid tablet consumption (42).

Community based cross sectional study design employed in Mecha district from June 25 -
July15/2013. The study was done to investigate factors associated with compliance of prenatal
iron folate supplementation. After multivariable analysis, shows, age of the mother, educational
status of the mother were significantly associated with compliance to iron folate supplementation
(P < .05)(43) .

The study conducted in two districts of Pakistan with aim to understand women and healthcare
providers’ perceptions, and to investigate the cultural and behavioral factors 10 influencing the
use of antenatal IFA supplements in rural and urban settings of Pakistan. The majority of women
were aware of the perceived benefits of antenatal IFA supplements. However, the rural women
had more limited information about the benefits of IFA supplements than the urban women(44) .

The cross sectional study conducted in luck now India to find out the economic determinants of
100 iron and folic acid tablet consumption overall, 83.5% of the women received 100 iron and
folic acid tablets during their pregnancy but, only 36.9% consumed them. Factors significantly
associated with consumption of 100 tablets, after simple logistic regression, were education,
parity, timing of ante-natal registration and number of ante-natal care visits to any facility.(45) ,

9
Nationally, there are substantial variations by women’s background characteristics. Twelve
percent of women under age 20 took iron tablets or syrup compared with 18 percent among
women age 25-34 and 17 percent among women age 35-49. The usage of iron tablets is much
higher among urban women, at 27 percent, than among rural women, at 15 percent. Also, the use
of iron tablets increases with levels of education and household wealth. The percentage of
women who took iron tablets ranges from 24 percent in Oromia region to 60 percent in
Tigray(46) .

1.5.2 Supplement and related factor

The leading reported Supplement and related factors for non-adherence were side-effects
(63.3%) and forgetfulness (16.7%). Forgetfulness and both perceived as well as experienced side
effects, considering them as contraceptives felt better thus stopped and Belief that too many
tablets would harm the baby of IFA therapy were the important factors for noncompliance(47) .

The common Supplement and related factors, which positively influence for taking the drugs,
were maternal health (32%) and fetal health (30%). Compliance increased with single daily dose
(30), they felt better after taking these supplements and they received support from family
members (36). Use of tablets as opposed to syrup increases the likelihood for antenatal ingestion
of iron-folate supplements for 90+ days in rural lower source set-up(48) .

According to EMDHS of 2014 there are substantial variations in the percentage of women who
took iron tablets by age, birth order, residence, region, education and household wealth. The
consumption of iron tablets is higher among urban women (41 percent) than among rural women
(33 percent). Nevertheless, there has been a more than two-fold increase in iron tablet
consumption among rural women in the last three years from 15 percent in 2011(49) .

1.5.3 Obstetric related Factor

The common Pregnancy and health related factors associated with compliance of iron folic acid
use were Prim parity and use of antenatal care. Compared to women who had 4 or more ANC
visits, those with 0, 1, 2 and 3 visits had 0.04, 0.33, 0.50 and 0.60times less odds of iron
supplement utilization, respectively. Mothers who visited antenatal care (ANC) for ≥4days were
more likely to take iron-folate supplements for 90+ days and be supplemented for more days (33)

10
than <4 days visitors (19). The facilitating factors for the women’s use of supplements were: they
had knowledge of benefits; Compliance increased with birth order, Knowledge on
supplementation for a minimum of 90 days predicted optimum supplementation, Knowledge on
when to start supplementation and importance of supplementation only predicted higher days of
supplementation, but not the optimum supplementation. Knowledge of anemia and iron folate
tablets and history of anemia during pregnancy were significantly associated with compliance to
iron folate supplementation (P < .05)(50) . The common barriers to iron and folic acid adherence
were, Women lacking comprehensive knowledge of anemia , the lack of antenatal care services
(50) .

1.5.4 Health service factor

The positive health and related factors that promote adherence of iron and folic acid
supplementation were trust in the healthcare providers and the availability of supplements, while
the non-availability of supplements promoted noncompliance(51) .

In addition, those who weren’t informed about the importance of iron supplementation during the
pregnancy had significantly lower utilization. It was also found that there was an association
between the consumption and the awareness created by the explanation of the health workers.
The consumption is more (82.4%) among the mothers who were explained properly than those
who were not explained (51.5%) by the health worker (52) . To increase the proportion of
pregnant mothers taking iron-folate supplements for 90+ days in low resource rural set-ups, there
should be intensified counseling/education on ANC attendance ≥ 4 times and on minimum
number of days for optimum iron-folate supplementation(17).

Community based cross sectional study supported with in depth interview was conducted to
assess compliance with iron folate supplement and associated factors among antenatal care
attendant mothers in misha district south Ethiopia. The compliance rate was found to be
39.2%.knowledge to anemia, knowledge to iron folate supplement and counseling on iron folate
supplement significantly associated with compliance to iron folate supplementation(53). In
addition those who were not informed about the importance of iron supplementation during the
pregnancy had significantly lower utilization(52). It was also found that there was an association
between the consumption and the awareness created by the explanation of the health workers.

11
The consumption is more (82.4%) among the mothers who were explained properly than those
who were not explained (51.5%) by the health worker(41).

12
1.5.5 Physical attribute and related factor

1.5.5.1 Side effects

While the nausea, vomiting and constipation that sometimes accompany early pregnancy may be
exacerbated by iron supplementation, there is little evidence that side effects are the major cause
of non-adherence. A study in Bangladesh confirmed that side effects of iron tablets had very
limited influence on adherence and recommended that efforts to reduce side effects may not be a
successful strategy for improving adherence(54). In Burma a small proportion (3%) of the
women stated that side effects were the reason they stopped taking iron supplements. Similarly
another study found side effects from iron therapy caused poor adherence in 1% of women(55).
InThailand, 30% of women complained of side effects while taking iron, however researchers
found that the side effects did not contribute to poor adherence because women were counseled
that side effects would subside(55).

1.5.5.2 Dose and form

Past studies have reported that the acceptability of supplements does not have significant effects
on the adherence(56) . Another study has shown that most women were satisfied with the size,
color, packaging, and instructions of iron/folate tablets(57) . Some studies have however shown
that the form in which iron tablets are given affects adherence (color. injection. tablet. liquid,
taste, etc.) For example, women in Mexico felt that iron injections were more effective than
tablets and that red iron pills were more effective than white or brown ones because the color red
is thought to strengthen and purify the blood(58)

1.5.5.3 Utilization of health services and personal believes

Physical distance to the clinic, economic constraints (cost of travel or the supplements) and
inconvenience of clinic hours have been thought to affect utilization of health services (59). In
many developing countries, use of any antenatal care service is often quite low (below 50%),
hence access to iron supplementation, usually delivered through the health care system can be
equally low. Beliefs about health and treatment may also interfere with iron adherence. Some

13
women in Thailand decided not to take supplements because they thought iron caused bigger
babies and difficult deliveries(60) . Compliance with iron supplementation was better in Mexico
when women sought early prenatal care because many of the late comers felt that iron was only
absorbed during the first third of pregnancy and was not effective after the first trimester(46).

1.5.5.4 Fluctuation in supplies

Inadequate and sporadic supplies of iron tablets as well as the failure to distribute them emerge
as barriers to adherence (57). Although it is a policy in most developing countries to give iron
supplements to pregnant women, clients are often not given enough pills to effectively improve
their iron status. This may be due to the following reasons: lack of overall government resources,
a low priority for health expenditures within the government, and a lack of awareness of policy
makers about the importance of iron supplements (29). Supplies seems to have also been found
to be a problem in Indonesia where 83% of participants in the Nutrition Development Program
said they had never seen iron tablets (34).On further investigation, it was found that the health
care professionals had not distributed iron because they did not understand its(41)

14
 1.6 CONCEPTUAL FRAME WORK

Women’s awareness
Obstetric factor Health service factor
Knowledge of anemia
Parity gravid Shortage of supplement in
Sossssss Knowledge about benefit of IFA facility
Abortion and its duration of taking
Health education
still birth
Adherence to iron Health worker
Number of ANC visit
and folate
Availability of health
Socio-demographic institutions
factor
Physical attribute factor
Age Family size

Marital status Side effect

Maternal education Forgot fullness

Socio economic status
Unpleasant test
Residence
Fear of become big weight

Fear of harm to the baby

Figure 1.1 show associated factor of iron folate supplement for pregnant mother at WCSH,
2023 (16, 46, 32, 50, 54)

15
 2. OBJECTIVE

2. 1 GENERAL OBJECTIVE

To assess the adherence and factors associated to iron and folic acid supplements among
pregnant women attending antenatal care at Woldia Comprehensive Specialized hospital from
January 20 to February 10, 2023

2. 2 SPECIFIC OBJECTIVES:

 To determine the level of adherence to iron and folate supplement among ANC
attendants, at Woldia Comprehensive Specialized hospital from January 20, to February
10,2023
 To identify factors affecting adherence to iron/folate supplement among ANC attendants,
at Woldia Comprehensive Specialized hospital from January 10, to February 20, 2023

16
3. Methods and Materials

3. 1. Study Area and Period

The study will be conducted at Woldia comprehensive and specialized Hospital which is found
in Woldia town, North Wollo Zone, Amara region, Northern Ethiopia. It will be conducted
within a period of November,20 to January,10,2022/2023. Woldia Town is 70 kilo meters (KM)
away from Dessie and 521 KMs from north of Addis Ababa, the capital city of Ethiopia and 360
Km from the Regional capital city, Bahirdar. Currently Woldia town has one governmental
comprehensive and specialized hospital, two health centres and eight private clinics. The
Hospital built in 1953 E.C by American missionaries to serve about 500,000 people according to
hospital standard, but now it provide outpatient and inpatient services for more than two million
people living in its catchment. The hospital gives different services for its clients like outpatient,
emergency, and maternal and child health services.

3.2. STUDY DESIGN

Institutional based cross sectional study design will be conducted to determine the adherence
level and factors affecting adherence to iron/folic acid supplements.

3.3. SOURCE OF POPULATION

The source populations will all pregnant women attending ANC at Woldia Comprehensive
Specialized Hospital

3.4. Study population

All sampled pregnant women will have ANC follow up during the study period.

3.5. INCLUSION AND EXCLUSION CRITERIA

3.5.1 Inclusion criteria

All pregnant women who will come for 2nd and above ANC visit during data collection period at
Woldia Comprehensive specialized Hospital.

17
3.5.2 Exclusion criteria

Pregnant women who will come for the antenatal visit, those who will not able to hear and/or
speak and those who will have mental disorder were excluded.

3.6 SAMPL SIZE DETERMINATON

The sample size of this study was calculated by using the formula to estimate a single

Population proportions

n = (Z α/2) 2 p (1-p)/ d2

n = sample size,

Z α/2= significance level at α =0.05

P= established prevalence from previous studies of the topic of interest (Adherence rate) in eight
rural district in Ethiopia (p=74.9%) (61).

d = margin of error of 0.05

Therefore, based on using the above single population proportion formula the sample size can be
calculated as: n= (1.96)2 0.749(0.251)/ (0.05)2

n=288

They have also non respondent rate which is 10% of the sample size plus sample size it 316.

3.7 Sampling technique

Participants will be selected using systematic random sampling technique. The first participant
was selected using simple random sampling technique. By using number of study population (N)
is their monthly achieved ANC follow up reports. Then we calculate K ;

18
3.8 Data collection instrument

A structured questionnaire will be used. The questionnaire will be prepared in English and
translated in to Amharic and back translated to English to check for its consistency for
quantitative data. Main points will be included in the questionnaire are socio demographic
characteristics, knowledge on anemia, benefits of iron/folate, health related characteristics and
health education during supplement collection in the health facility.

3.9 Data collection procedure

Data will be collected using pretested interview administered questionnaires. The questionnaire will be
translated to Amharic. The questionnaire addressed the women socio demographic
characteristics, knowledge on anemia, benefits of iron/folate and health related characteristics.

3.10 Data quality assurance

To ensure quality of data, training will be provided to data collectors and supervisors, data collection
material will pretest using 5% of similar population of adago Health Center. Regular supervision will be
provided during data collection. Collected data will be manually checked for completeness, accuracy and
clarity on daily basis. Pretest will be conducted on ANC follow up on adago health center which is
approximately 1km from Woldia comprehensive specialized Hospital, but it will have Similar
situation with to test its variability and subjects, who will be involved in the pre-test excluded
from the study, then the questionnaire will be assessed for its clarity, length and completeness
and the necessary correction will be done accordingly.

3.11 data processing and analysis

The collected data will be checked for completeness and accuracy and then will be analyzed by
SPSS. Descriptive analysis will be performed to know frequency and percentage. The analyzed
data will be presented using tables, pi-charts and bar graphs.

3.12 Dependent Variable

Adherence to Iron and foliate supplementation

19
3.12 Independent variables:

3.12.1 Socio-demographic factors:

• Age
• Religion
• Marital status of the mother
• Educational status
• Occupations

3.12.2 PREGNANCY AND HEALTH RELATED FACTORS:

• Parity
• History of still birth
• History of abortion
• Number of ANC
• Place of ANC
• Number of ANC visit

3.12.3 Health care and system related factors:

• Distance from health service

• Number of supplement per visit
• Health education at the time of supplement collection
• Number of iron and folate supplement collected per visit

3.13 ETHICAL CONSIDERATION

Ethical clearance will be obtained from Ethical review committee of Woldia Comprehensive specialized
hospital and will be offered to the data collectors. The purpose and the importance of the study will be
explained and will be informed and Confidentiality will be maintained at all level of the study.
Participant’s involvement in the study will be on voluntary bases and that they can withdraw any
time if they want. All the information will be given by the respondents will be used for research
purposes only. Confidentiality and privacy will be maintained by omitting the name of the
respondents during data collection procedure.

20
3.14 OPERATIONAL DEFINITION OF VARIABLES

3.14.1 Knowledge to anemia:

Those who will score mean value and above of correct response about cause, consequence, risk
group and method of prevention of anemia will be considered as they are knowledgeable of
about anemia while those who will score less than mean value of correct response considered as
they are not knowledgeable about anemia(12).

3.14.2 Knowledge to benefits of Iron/folic acid:

Those who will score mean ; value and above of correct response about benefits of iron/ folic
acid are considered as they are knowledgeable about of benefits of iron folic acid while those
who will score less than mean value of correct response considered as they are not
knowledgeable benefits of iron folic acid(12).

3.14.3 Antenatal services:

Pregnancy check-up by health personnel, provision of iron/folic acid

Supplements, tetanus toxoid vaccination and health education and counseling(62)

3.14.4 Adherence:

Mothers are said to be adhered to IFA supplement if the 65% or more of the supplement,
equivalent to taking supplement at least 4 days a week during three month period(63).

3.14.5 Non adherence:

Pregnant mother is said to be not adhered to IFA supplement if they took less than 65% of the
supplement, equivalent to taking supplement less than 4 days a week during three month
period1(63).

21
5. RESULTS

5.1 Socio-demographic characteristics

From a total of 316 pregnant women, 306 8%.The mean age of the respondents was 25.49(±5.29)
years. Around 139 (45.4%) of respondent were in age group of (20-25] years and about 56 (18.3
%) were in age group of (30-36] years. Majority of the women were married 278 (90.8 %) and
rural 179(71.6) dwellers. About 164(53.6%) were unable to read and write, 19 (6.2%) were can
read and write. Regarding occupation majority of the respondent were house wives (33.3%). (See
Table 1)

Table 1: Socio-demographic and economic characteristics of respondent of pregnant

Women, At WCSH, East Ethiopia. (n=306)

FREQUENCY Percent (100%)

Age in years

<=20 49 16.0

(20-25] 139 45.4

(25-30] 51 16.7

(30-36] 56 18.3

>=37 11 3.6

Marital status

Single 0 0

Married 278 90.8

Divorced 25 8.2

22
Widowed 3 1.0

Religion

Orthodox 248 81.0

Catholic 0 0

Muslim 49 16.0

Protestant 9 2.9

Residence

Rural 219 71.6

Urban 87 28.4

Educational level of mother

Can’t read and write 164 53.6

Can read and write 19 6.2

Primary 39 12.7

Secondary 47 15.4

Above secondary 37 12.1

Occupation of mother

House wife 102 33.3

Governmental employee 43 14.1

Private employee 30 9.8

Daily laborer 6 2.0

Merchant 52 17.0

23
Farmer 73 23.9

24
5.2 Pregnancy and Obstetric related characteristic of respondent

Above two third 246 (80.4%) of the respondents had two times ANC visit. About 119(38.9%) of
the respondents have history of abortion and 33 (10.8%) have history of still birth. Among the
respondents 96(31.4%) have started ANC while their pregnancy is less than 12weeks gestation,
and 72 (23.5%) have started after 16 week of gestation (Table 2).

TABLE 2: PREGNANCY AND OBSTETRICS RELATED CHARACTERISTIC OF RESPONDENT AT

WCSH, N ORTH EAST ETHIOPIA . (N=306).

Variables Frequency Percent (100%)

Gravidity

Prime 148 48.4

Multi 158 51.6

Still birth

Yes 33 10.8

No 273 89.2

Abortion

Yes 119 38.9

No 187 61.1

Number of ANC visit

2 246 80.4

>=3 60 19.6

25
Time of start ANC

<12weeks 96 31.4

12- 16 weeks 138 45.1

>16weeks 72 23.5

Presence of diseases
during

Pregnancy

Yes 107 35.2

No 199 64.8

Type of diseases

Gestational hypertension

Pregnancy induced 55 51.3

diabetes mellitus

APH 25 23.4

OTHERS 11 10.3

Total 16 15.0

107 100

26
5.3 Respondents knowledge of anemia and benefit of Iron and foliate
supplements

Around 153(50.0%) respondents had good knowledge on cause, consequence, risk group, and
method of prevention on anemia, while 229(74.8%) of respondents had good knowledge on
benefits of iron and foliate (see table 3).
TABLE 3: RESPONDENTS KNOWLEDGE ON ANEMIA AND BENEFIT OF IFA S UPPLEMENT
AT WCSH, N ORTH EAST ETHIOPIA .

Variables Frequency Percent (100%)

Knowledge Category on
anemia

Good 153 50

Poor 153 50

Knowledge about
of IFA
229 74.8
Good
77 25.2
Poor

27
5.4 Health care Service related characteristics

About 114 (37.3%) were received Health education and 192 (62.7%) were not educated about
iron/folic acid supplements. Regarding dispensing of supplement majority of respondent
165(53.9%) was taken <59 tablets per three months and 141 (46.1%) were taken >=59 tablets per
three month.
TABLE 4: SERVICE RELATED CHARACTERISTICS , AT WCSH, N ORTH EAST ETHIOPIA .
(N=306)

Variables Frequency Percent (100%)

Health education

Yes 114 37.3

No 192 62.7

Waiting time

<3 hours 7 2.3

3-6 hour 184 60.3

6-8 hour 115 37.4

Problem faced during

follow up

Long waiting time 246 80

Lack of supplement 30 9.8

Poor health care 30 9.8

28
5.5 Adherence level of women to iron/foliate supplementation during
pregnancy

It was found that 46.08 of women had adherence. While 53.92 of them had not adhered to Iron
and foliate supplementation.
TABLE 5: LEVEL OF ADHERENCE RELATED CHARACTERISTICS , AT WCSH, N ORTH EAST
ETHIOPIA . (N=306)

Variables Frequency Percent (100%)

Level of adherence

Adhere 141 46.08

Non adhere 165 53.92

Reason for not taking the

supplement

Forgetfulness
105 51.7

Fear of side effect

89 43.8

Presence of other drug

9 4.4

29
Figure 3; Adherence level to iron and foliate at WCSH Hospital, North East Ethiopia 2023

46.08%
53.92%

30
5.6 Reasons for not taking the supplement

The study Showed that the reasons for poor adherence to IFA supplement includes forgetfulness
(49.7%), due to fear of side effect (44.8%) and presence of other drugs they had taken (5.6%).

5.7 Determinants factors on adherence of iron and folate supplements among

pregnant women

Based on the result of bi-variable binary logistic regression analysis, the following variables
residence of respondent, educational status, number of visit in current pregnancy, presence of
previous abortion, presence of more visit, educational status, presence of health problem during
pregnancy, presence of knowledge on anemia were included in the multivariate logistic
regression analysis since their p-value was <0.25.

In multivariate logistic regression analysis result educational status of pregnant mother, number
of pregnancy, having health problem in the current pregnancy and knowledge about anemia had
significant association with adherence to IFA supplement.

Pregnant women who cannot read and write were 77% less (AOR =0.233, 95% CI: 0.082, 0.664)
likely to adhere to iron and folate supplement than women who were graduated in college. Prime
gravid Pregnant women were 89% less likely (AOR=0.111, 95%CI: 0.057, 0.216) to adhere
than multigravida pregnant women. Pregnant women who had health problem during current
pregnancy were 56% less likely (AOR=0.439, 95% CI: 0.2o4, 0.945) to adhere than those
pregnant women who were healthy.

In addition pregnant women who had poor knowledge about anemia were 2 times (AOR= 2.089,
95% CI: 0.972, 4.493) less likely adherent than pregnant women who had good knowledge about
anemia.

31
Table 6: Bi-variable and multivariate logistic regression analysis of adherence of IFA
supplement and associated factors among pregnant women attending ANC at WCSH, Woldia,
Ethiopia, 2023. (n=306)

Variable(n=306 Non adherence COR AOR

adherence
F (%) F (%)
Age in yrs. <=20 28(57.1) 21(42.9) 0.625(0.168-2.327)
(20-25] 78(56.1) 61(43.9) 0.652(0.19-2.237)
[26-30] 27(52.9) 24(47.1) 0.741(0.200-2.740)
(30-36] 27(48.2) 29(51.8) 0.895(0.245-3.276)
>=37 5(45.5) 6(54.5)
Marital single 0
status of married 154(55.4) 124(44.6) 0.430(0.036-4.492)
women Divorced 10(40.0) 15(60.0) 0.750(0.060-9.418)
Widowed 1(33.3) 2(66.7)
Religion Orthodox 139(56.0) 109(44.0) 0.627(0.165-2.392)
Muslim 22(44.9) 27(55.1) 0.982(0.235-4.104)

Protestant 4(44.4) 5(55.6)

Other 0
Residence Rural 140(63.9) 79(36.1) 0.228(0.133-0.390) 0.977(0.434-2.200)
Urban 25(28.7) 62(71.3)
Education Can read 5(26.3) 14(73.7) 1.704(0.504-5.763) 0.643(0.123-2.950)
and write
Can.t 115(70.1) 49(29.9) 0.259(0.123-0.546) 0.233A(0.082-0.664)*
1-8 18(46.2) 21(53.8) 0.710(0.284-1.774) 0.278(0.079-0.974)
9-12 13(27.7) 34(72.3) 1.592(0.633-4.002) 0.974(0.314-3.016)
College 14(37.8) 23(62.2)

32
Occupation House 55(53.9) 47(46.1) 1.095(0.598-2.004)
wife
Governme 24(55.8) 19(44.2) 1.014(0.475-2.167)
nt
employee
Private 14(46.7) 16(53.3) 1.464(0.624-3.437)
worker
Labor 4(66.7) 2(33.3) 0.641(0.110-3.721)
Merchant 27(51.9) 25(48.1) 1.186(0.581-2.422)
Farmer 41(56.2) 32(43.8)
Pregnancy Prime 127(85.8) 21(14.2) 0.052(0.029-0.094) 0.111(0.057-0.216)*
Multi 38(24.1) 120(75.9)
Presence of Yes 17(51.5) 16(48.5) 1.114(0.541-2.296)
still birth No 148(54.2) 125(45.8)

Abortion Yes 96(80.7) 23(19.3) 0.140(0.081-0.241) 0.385(0.178-0.830)

No 69(36.9) 118(63.1)
Number of 2 146(59.3) 100(40.7) 0.317(0.174-0.579) 0.745(0.342-1,624)
visit in >=3 19(31.7) 41(68.3)
current
pregnancy
Presence of Yes 86(80.4) 23(19.6) 6.248(3.583-10.894) 0.439(0.204-0.945)*
health No 78(39.6) 119(60.4)
problem in
current Px
Knowledge Poor 77(50.3) 76(49.7) 1.336(O.851-2.097) 2.089(0.972-4.493)*
about anemia Good 88(57.5) 65(42.5)
Knowledge Poor 63(81.8) 14(18.2) 0.178(0.095-0.337) 0.583(0.249-1.367)
about IFA Good 102(44.5) 127(55.5)
Presence of Yes 58(50.9) 56(49.1) 2.506(1.278-3.473) 1.095(0.494-2.428)
learning No 110(57.3) 82(42.7)

33
during ANC

34
6. DISCUSSION

This study was aimed to assess adherence to iron/folic acid supplement and associated factors
among ANC attending mothers in WCSH, Woldia and found that 46.08% of pregnant mothers
were adherent to the supplement and maternal educational status, knowledge about anemia,
developing any other health problem during the current pregnancy were factors associated to iron
folic acid supplement. This finding has less consumption of IFA tablet when compared with the
finding of studies conducted in south India (64.7%), Asella town (59.8%),Gulele sub city
(62.3%) and Akaki Kality; Addis Abeba (60.9%)(21,32,33,34). However, it is higher when
compared with studies conducted in Uganda, eastern Kenya, North Western Zone of Tigray,
Ethiopia, and South East Ethiopia in which the proportion of participants adhered to the
supplement were 12%, 18.3, 37.2%, and 18%, respectively (35, 36, 37, 38).this discrepancies
were due to differences in population considered for the study and the time period used for
assessing adherence behavior.

This study found that mothers who had no formal education were more likely non-adherent to
iron/folic acid supplements compared to those who attended collegeand above educational status.
This might be due to the effect of educational status on health literacy level which affects the
ability to differentiate the benefit and risks of adhering to the supplement (32, 36). In addition
those mothers who educated more can have exposure to different sources of information
promoting benefits of adhering to the supplements (33).

The study participants who had poor knowledge about anemia were more (AOR= 2.089, 95%
CI: 0.972, 4.493) likely non-adherent to combined iron/ folic acid supplements compared with
those who had good knowledge about anemia. This finding is consistent with a study conducted
in Hosanna town, Ethiopia, and eight rural districts of Ethiopia which found that those who had
no comprehensive knowledge about anemia less likely utilize the Iron supplement

35
7. Conclusion

 According to this study nearly half of pregnant mothers were adherent to IFA
supplement.it showed that more than half of pregnant mothers were non-adherent
to IFA supplement. Educational status of pregnant mother, number of pregnancy,
having health problem in the current pregnancy and knowledge about anemia had
significant association with adherence to IFA supplement.

8. RECOMENDATION
 for community Leaders
1) Encourage the pregnant women to attend their ANC by
communicating with health workers.

 Woldia Health Bureau

2) Sensitization of the community about anemia and Iron and foliate

supplement during pregnancy through health Education.
3) Engaging the extension health workers to educating the pregnant
women about ANC visit and about benefit of iron folic acid
supplement.

 WCSH Hospital MCH Ward

● Give health education regarding the importance of Iron/Foliate
supplementation during pregnancy.

a) Research committee

1) Longitudinal study should be done to evaluate IFA supplement adherence for the
improvement of maternal health and on dietary adequacy

36
b) Limitation of our study

2) Gold standard method of measuring adherence like electronic and pills

counting method were not used as it is expensive.
3) Cross-sectional study design was used. This type of study design shows the
exposure and outcome at the same point in time, so that we cannot
formulate a cause and effect relationship.

37
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 ANNEXES

ENGLISH VERSION CONSENT & QUESTIONNAIRE

Questionnaire

Hello. My name is _______________________________I am conducting a survey on the factors

associated with adherence to Iron/foliate supplementation among pregnant Women attending
antenatal care as part of the partial requirement to graduate with Bachelor degree in Midwifery.

You have been selected by chance among other participants. I would like to ask you
somequestions related to this study. Participation in this survey is voluntary and you can choose
not to take part. There will be no injections, drawing of blood or any body fluid involved. All
information you will give will be confidential and will be used to make a general report. No
names will be included in the report and there will be no way to identify you as one of the people
who gave information.

If you have any questions about the survey, feel free to ask me. Do you mind if weproceed?

Respondent agreed to be interviewed: Circle one

1. Yes 2. No

43
Socio-Demographic and economic Characteristics
S.n Questions Responses
o
What is your age
What is your current marital status 1) Single
2) Married
3) Divorced
4) Widowed
Religion 1) Orthothodox
2) Muslim
3) Protestant
4) Other
Place of residence 1) Rural
2) Urban
Total family size
Educational status 1) can’t read and can’t write
2) can read and can write
3) Grade(1-8)
4) Grade(9-10 )
5) Grade(11-12)
6) College
Occupation 4) House wife
5) Government employee
6) Private employee
7) Labor
8) Merchant
9) Farmer
10) Other(specify
Educational status of your husband 1) can’t read and can’t write
2) can read and can write
3) Grade(1-8)
4) Grade(9-10 )
5) Grade(11-12)
6) College
Current occupation 1) Farmer
2) Government employee
3) Private employee
4) Labor
5) Merchant
6) Farmer
7) Other(specify
Annual income 1) In birr---
2) Other(specify)--------

44
Pregnancy and health status characteristics
s.no Questions Responses
1 How many pregnancies did you have
till now? (number
2 How many deliveries you had till
know?
3 Did you have history of still birth? Yes
No
4 If yes, how many still births did you
have?
5 Did you have history of abortion? Yes
No
6 If yes how many abortions did you
have?
7 Did you have ANC follow up for the Yes
previous pregnancies? No
8 How many visit did you receive ANC 1
2
3
4
9 At what gestational age did you start
ANC? In weeks
10 Where did you receive ANC follow Health center
up Hospital
Others
11 Did you have any health problem Yes
during this pregnancy? No
12 If yes, Tell me which health problem Hypertension
you have faced? Diabetes mellitus
Antepartum hemorrhage

45
 Others
13 Have you taken medication for Yes
problem you faced? No
14 For how long did you take the
medication?
Knowledge on anemia and its prevention
s.no Questions Responses

1 Did you know about anemia? Yes

No
2 What is your source of information? 1) Health worker 6)
2) Media
3) School
4) Friend
5) Others
3 Did you know the cause? 1) Yes 3)
2) No
4 If yes, what is the cause? 1) Unbalanced diet 6)
2) Iron folate deficiency
3) Blood loose
4) Being werried
5) Others
5 Did you know what anemia results in 1) Yes 3)
pregnancy? 2) No
6 If yes, what are they? 1) Maternal mortality 12)
2) Still birth
7) Infant mortal
6
If yes, what are they?
3) Maternal mortality
4) Still birth
5) Infant mortality
6) Impaired development
7) Others

46
 8)

7
What are the most susceptible groups to
anemia?
1) Pregnant women
2) Children
3) Non pregnant women
4) Adult
5) Others
6)

9) ity
10) Impaired development
11) Others
7 What are the most susceptible groups 7) Pregnant women 12)
to anemia? 8) Children
9) Non pregnant women
10) Adult
11) Others
8 Does anemia can be prevented during Yes
pregnancy? No
9 If yes, how does it can be prevented? 1) Dietary iron/folate 6)
2) Avoidance of foods that interferes
bioavailability of iron
3) Taking iron folate tablet
4) Adequate fluid taking
5) Others
Knowledge on iron/foliate supplement categories
1 Do you know the drug called a) Yes c)
iron/folate b) No
2 Do you know the benefit of iron/ a) Yes c)
folate supplement?

47
 b) No
3 If yes what is the benefit of taking a) prevent maternal death g)
iron /folate supplement /more than b) prevent fetal death
one answer is possible c) prevent infant death
d) prevent birth defects
e) Give strength for the mother
f) Other
4 Do you think that iron/folate a) Yes c)
supplement has risk for health? b) No
5 If yes what are the risk? a) harm fetal growth e)
b) cause for big fetus
c) result to complicated delivery
d) other

Physical attribute and related factor

1 Have you taken iron /folate a) Yes
supplementation for current b) no
pregnancy?
3 How did you take your supplement? c) Daily f)
d) Weekly
e) Other
4 How many In the first months
tablet did you of supplement?
take In the second
months
In the third
months
Totally

48
5 If you had not taken the supplemented a) Forgotfullness
iron /folatefully, what is the reason? b) Because of many pills
c) Fear of side effect
d) Unpleasant test
e) Difficulty during delivery
f) Failure to get adequate
supplement
g) Others

Health care and system related factor

How long it takes to reach health institution from your resident? …..
1
2 Is there any health education about iron folate supplement during Yes
follow up No
3 If yes, what about they teach? 4) About purpose 8)
5) About side effect
6) About duration of
supply
7) About follow up visit
4 How many tablets did you take per visit? 1) 30 5)
2) 60
3) 90
4) >90
5 What is the average waiting time in the health facility during …….
taking iron and folate

6 Do you face any problem in the facility while you are receiving Yes
your supplement No
7 If yes, which problem do you face? 1) Shortage of 5)
supplement
2) Long waiting time
3) Poor health care
provider
communication

49
 4) others

Thank you!!!

50