Barriers to Adherence to Iron Supplements in Pregnancy in Rural South India

Introduction

Iron requirements in pregnancy are higher than those in the non-pregnant state and increase with increasing gestational age. A 55 kg pregnant woman requires approximately 1000mg of iron throughout pregnancy. She is therefore expected to enter pregnancy with iron stores of at least 300mg, failing which, deficiency of iron resulting in anemia is inevitable1 . Given the poor bioavailability of dietary iron, iron supplementation programmes during pregnancy are a necessity if anemia in pregnancy is to be prevented¹ . The strategy however has met with success only when individuals are compliant to iron supplements² . Compliance is therefore a necessity if iron supplementation programmes worldwide are to be successful. Compliance however is a complex phenomenon influenced by individual, socio-cultural and environmental factors that need to be addressed if optimum levels of compliance are to be attained.

Despite ongoing iron supplementation programmes worldwide the prevalence of anemia in pregnancy ranges from 47% in Africa to 80% in the Southeast Asia³ . The situation in the Indian subcontinent is no different with prevalence rates of anemia in pregnancy as high as 58% despite iron supplementation programmes since the 1970s⁴ . Low adherence to iron supplements is thought to be the cause for poor performance of the programme. Inadequate supply, packaging, fear of large babies and forgetfulness were a few barriers to iron supplementation identified in the past⁵ . However, the changing socio-cultural scenario and the persistently high prevalence of anemia in pregnancy, necessitate studies that identify prevailing barriers of adherence to iron supplements for the success of these programmes. Given the current scenario we aimed to assess the levels adherence and barriers to iron supplementation in antenatal women at a private secondary level obstetric healthcare center in rural South India.

Materials and Methods

This is a cross-sectional study done between March and May 2011 at a rural private obstetric healthcare center in rural Karnataka. Study group included 150 antenatal women who had completed 20 weeks of gestation and received iron supplements for at least one month. Verbal informed consent was obtained from all participants in the presence of a witness.

A pretested, interviewer administered questionnaire was used to assess barriers to adherence to iron supplements in the study participants. Knowledge was assessed for the domains of anemia and iron supplements including side effects of iron supplements. A score of ≥ 3for the anemia domain and ≥ 2 for the iron supplements domain was considered “adequate knowledge”. Participants were asked to rate their adherence as a percentage based on the prescription obtained at the last antenatal visit. Adequate adherence was defined as an adherence rate of ≥80%.Additionally, demographic and clinical characteristics of the participants were also obtained.

The quantitative data was supplemented by qualitative data obtained through focus group discussions (FGD) with husbands and mothers of antenatal women attending the antenatal clinic at the study site. Key informant interviews (KII) were also conducted with the medical officer and pharmacist at the study site and the multipurpose worker and medical officer at the nearby public healthcare facility.

Data was entered and analyzed using Microsoft excel and SPSS. Frequencies, mean, and standard deviation were used to describe the data. The Chisquare test, unpaired t test and binomial logistic regression were used to compare demographic and clinical characteristics of the participants with adherence. Qualitative data from the FGDs and KIIs were compiled and key themes identified.

Results

Table 1 describes the demographic and clinical characteristics of the 150 antenatal women who participated in the study. 

Adherence: The mean adherence rate in our study was 74.65% ± 26.73%. It was 82% and 73% in women in the 2nd and 3rd trimesters respectively (p>0.05). Of the participants, 87 (58%) were found to be adequately adherent to iron supplements since their last visit and 11(65%) and 76(57%) of the women in their 2nd and 3rd trimesters were adequately adherent to iron supplements (p>0.05). Stool was reported to be black in color by 62 (41%) of the participants.

Barriers to adequate adherence Side effects (eg; nausea, vomiting, constipation, discoloration of stool) (43%), forgetfulness (32%), perception that iron tablets were not good for their baby’s health (3%) and a difficult delivery resulting from a big baby(2%)were reasons cited by the women for not being adequately adherent to the iron supplements.

Themes identified as barriers of adherence from qualitative data were, (I ) Medication side effects like burning in the chest, constipation and diarrhea (ii) Behavioral factors i.e. forgetfulness and negligence towards taking medications attributed to “not being used to taking medications” (“Matre togondu abhyasa illa”) (iii) Inadequate knowledge regarding medications i.e. “confusion” resulting from the advice given by several well-wishers, inadequate advice from the healthcare practitioner (iv) Issues with the healthcare system i.e. lack of supply of iron tablets and prescriptions that lasted beyond a month.

Determinants of non-adherence Participants not encouraged by spouse or family to take iron supplements less likely to be adherent to iron supplements than those who were encouraged (p<0.05). The significance was maintained on adjusting for other demographic and clinical variables in a logistic regression model (p<0.05, OR=0.37, CI=0.15-0.91). No significant association between adherence and demographic and clinical characteristics like age, education, socioeconomic status, religion, trimester, knowledge regarding anemia and iron supplementation and advice given by the healthcare provider were found in our study.

Discussion

Adherence is the result of complex interactions between socio-environmental conditions, health care system, medication use system and patient characteristics (eg; memory)6 . Adherence to iron and folic acid supplements is the key to prevention of anemia in pregnancy. We therefore aimed to assess the levels of adherence, its barriers in antenatal women such that suitable strategies may be identified to address these barriers in the context of rural South India.

Despite a 74% adherence rate, nearly 40% of the women in our study were not adherent to iron supplements. Jasti S et al reported an adherence rate of 74% by pill count, at an antenatal clinic in North Carolina⁷ ; this was similar to the mean adherence rate in our study. A study in Cambodia found 47% of the women interviewed to be adherent to iron supplements⁸ . The finding was lower than that observed in our study (58%). Similarly, Ordenes MAC et a reported 54% of a cohort of pregnant women to be optimally adherent to iron supplements in the city of Muntinlupa⁹ . However, an adherence rate of >90% by pill count was used to define “good adherence” unlike our study which used a cut off 80% by self report. De Souza AI et al, reported 92%, 83% and 71% of antenatal women to be adherent to iron supplements in the 1st 2nd and 3rd trimesters of pregnancy respectively¹⁰. Similarly, we found fewer women adherent in the third trimester than in the 2nd trimester. Habib et al found an equal number of women to be adequately adherent and not adherent to medication in a Saudi Arabian study¹¹. Differing definitions of adherence and study locations may have resulted in the differences in adherence rates observed between studies.

Side effects of medications were identified to be the most common reason for non-adherence in our study similar to the finding in Senegalese pregnant women¹². On the contrary, though side effects to iron tablets were reported in studies from Cambodia and Bangladesh they were not considered as barriers of adherence¹³. Women in these studies continued to take their iron supplements despite side effects which they realized subsided after the first few days. Interventions that target side effects of iron tablets were thought to be of limited use for the improvement of adherence in these studies¹¹. The findings were reinforced by Erkstrom EC et al from Tanzania who suggested that reasons for non-adherence go beyond just the side effects of iron supplements¹⁴. On the contrary, Galloway et al suggested that side effects of iron supplements should not be ignored, and doses should be built up over time if women complain that the side effects are intolerable² .

Forgetfulness, another barrier to adherence reported in literature was also identified in our study^12,15. Negligence another barrier to iron supplementation, identified in our study through qualitative methods was thought responsible for the forgetfulness reported by some women. Counselling regarding the importance of adherence to medication, cue dose training and personalised reminders have proved successful in addressing forgetfulness in chronic diseases^2,16, could also be used to improve adherence to iron supplements in pregnancy. Most women in our study who reported forgetfulness as a reason for missing medications thought medication reminders could be helpful in improving adherence. Similar findings were also reported by Pearson AK al¹⁷.

Reinforcement and communication by the healthcare provider have been identified as factors that promote adherence to iron supplements² . While none of the antenatal women in our study attributed non-adherence to lack of advice given by the healthcare provider, only 1/3rd of the antenatal women reported that they had received any kind of advice regarding iron supplements. The need for advice regarding iron supplementation, expressed by spouse and parents of antenatal women in our study reinforces the need for communication by the healthcare provider.

Beliefs that consumption of iron supplements may lead to or a big baby and difficult delivery, reported in literature were also identified in our study⁵ . However, only 3% of non-adherent participants reported this belief, indicating that it was no longer a major barrier to iron supplementation in pregnancy in this study setting.

Barriers like cost and poor access to iron supplements, inadequate supply, appearance, and packaging of prescribed supplements did not affect adherence in our study unlike many other studies^5,18. This was probably due to the study setting that ensured continuous supply of affordable iron supplements to antenatal mothers. In contrast, key informant interviews with healthcare workers at the nearby public healthcare facility revealed deficiency in the supply of iron supplements over the past 6 months. This did not affect adherence in our study as the study setting was a private facility.

The number of antenatal visits did not influence adherence in our study unlike the findings of Aikawa R et al in Vietnam¹⁸. This was probably because all women had had at least 3 antenatal visits in our study. The ability of antenatal visits to reinforce adherence and provide iron supplements has also been supported by Lacerte P et al⁸ .

The ability of family support to improve adherence to iron supplements is reinforced by our study. The findings are similar to those in studies of chronic disease where strategies like family group support improved adherence to medications¹⁹. Obtaining the cooperation of the spouse and family to ensure adherence to iron supplementation in antenatal women could go a long way in improving adherence as was observed in Vietnam study¹⁸. This could be achieved through counseling of the spouse and family regarding anemia and iron supplementation in pregnancy whenever they accompany the woman for antenatal care.

As in other studies demographic characteristics of the study population were not found to be good determinants of adherence. On the contrary Jasti et al and Galloway et al found that education and knowledge of anemia, its outcome and prevention improved adherence to iron supplements in pregnancy^2,5,7. Higher levels of education and income were found to be associated with good adherence by Tessema et al in USA²⁰.

Methodological issues

The study was done at a private, obstetric healthcare setting which may not have been representative of care provided at a public healthcare facility. However, considering that health care in India to a large extent is private; our study may still be a good representation of the actual situation in rural India. The clinic setting and affordable quality care provided by the facility may have resulted in higher adherence rates reported in our study. Also, the self-report used for adherence assessment in our study could have been an overestimate due to social desirability. Recall bias could also have influenced adherence both positively and negatively. Unlike some other studies, we did not study the effect of hemoglobin concentration on adherence or vice versa as our objective was to identify the barriers of adherence and not the outcome of good adherence.

Conclusion

The nearly 40% non-adherence to iron supplements implies that iron supplementation in the Indian setting is far from being successful. The major barriers to adherence like side effects of iron supplements and forgetfulness need to be addressed for the success of iron supplementation programmes in the Indian context. Education and counseling of antenatal mothers regarding the sideeffects of iron supplements and interventions that address forgetfulness, like personalized reminders, and encouragement by the family could go a long way in addressing non-adherence in the South Indian setting.