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Table of Contents
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 120-124

Adherence to iron with folic acid supplementation in women attending an antenatal clinic at a low-income urban area in Delhi, India

Department of Community Medicine, Maulana Azad Medical College, New Delhi, India

Date of Submission03-Aug-2019
Date of Decision15-Apr-2020
Date of Acceptance10-Oct-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Dr. Ekta Arora
Department of Community Medicine, Maulana Azad Medical College, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCFM.IJCFM_64_19

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Introduction: Adherence to Iron-Folic Acid Supplementation (IFAS) in pregnant women can safeguard them against nutritional anemia and the related adverse pregnancy outcomes. The objective of this study was to assess the adherence to oral IFAS in women attending an antenatal clinic in an urban resettlement colony of Delhi, India.
Material and Methods: We conducted a cross-sectional study and enrolled 211 antenatal women through consecutive sampling during a 4-month period from December 2018 to April 2019. IFAS adherent status was defined as women taking ≥80% of their prescribed IFAS in the previous 7 days, equivalent to IFAS intake for at least 6 days in the previous week. We also estimated adequacy of IFAS drug stocks with the patient during the past 30 days. The data were analyzed using IBM SPSS Version 25. A P < 0.05 was considered statistically significant.
Results: The mean (± standard deviation) age of the women was 24.6 (±3.4) years, ranging from 19 to 35 years. Median years of education was 11, and all the women were currently married. A total of 54 (25.6) women reported being non-adherent to their prescribed IFA medication. Only 175 (82.9%) women had adequate IFAS stocks during the past 30 days. On adjusted analysis, running out of IFAS stocks was a significant predictor of IFAS non-adherence (P = 0.004).
Conclusion: The present study indicates that adherence to IFAS among pregnant women is suboptimal. Non-adherence was usually because of running out of drug-stocks but rarely due to drug side-effects.

Keywords: Adherence, antenatal women, iron-folic acid supplementation

How to cite this article:
Basu S, Arora E, Singh M M, Garg S, Budh N. Adherence to iron with folic acid supplementation in women attending an antenatal clinic at a low-income urban area in Delhi, India. Indian J Community Fam Med 2020;6:120-4

How to cite this URL:
Basu S, Arora E, Singh M M, Garg S, Budh N. Adherence to iron with folic acid supplementation in women attending an antenatal clinic at a low-income urban area in Delhi, India. Indian J Community Fam Med [serial online] 2020 [cited 2021 Dec 6];6:120-4. Available from: https://www.ijcfm.org/text.asp?2020/6/2/120/304799

  Introduction Top

Anemia in pregnancy is a major public health challenge worldwide with an estimated 38.5% prevalence, affecting >56.4 million women.[1],[2] Nutritional anemia due to Iron Deficiency Anemia (IDA) is the predominant cause of anemia in the developing world.[3] Anemia during pregnancy is considered as a hemoglobin concentration <11 g/dl, with >10 g/dl as mild anemia, between 7 and 9.9 g/dl as moderate anemia and <7 g/dl as severe anemia.[4] Factors such as dietary deficiency, iron inhibitors in diet, poor iron stores in childhood and adolescence, iron losses during postpartum hemorrhage, teenage pregnancy, repeated pregnancies with inadequate spacing and poor sanitary conditions increase the risk of IDA in women undergoing pregnancy in the developing world.[5]

The National Family Health Survey 4 (NFHS 4) reported 50.3% of pregnant women in India were anemic. Mild, moderate and severe anemia was observed in 24.5%, 24.6%, and 1.3% of the women, respectively. In the Indian capital city, Delhi, the prevalence of anemia among pregnant women was 45.1%.[6]

It is well-established that IDA causes multiple adverse outcomes for both the mother and infant, including an increased risk of hemorrhage, sepsis, maternal mortality, perinatal mortality, and low-birthweight.[7] Furthermore, anemia in pregnant women is estimated to contribute to >115,000 maternal deaths and 591,000 perinatal deaths globally per year.[8] Anemia is also considered as the underlying cause for 20%–40% of maternal deaths in India.[5]

Iron requirements in pregnancy increase by an estimated 850 mg for red cell expansion, growth of the fetus, placenta, and the uterus, additional needs that cannot be met by diet alone and require the utilization of body iron stores.[9] Current prevention and control strategies for IDA for women in India are therefore focused on iron-folic acid supplementation (IFAS) during pregnancy after the first trimester as means of preventing anemia and related complications.[10] However, poor adherence to IFAS is a major challenge in Indian health settings. Findings from the NFHS-4 reveal that only 52% of women took the recommended 100 IFA pills during their previous pregnancy.[6]

There is a paucity of Indian studies which have assessed factors associated with poor IFA intake during antenatal care. We conducted the present study with the objective of assessing the adherence to oral IFAS in pregnant women attending an antenatal clinic in an urban resettlement colony of Delhi, India.

  Material and Methods Top

Study site

We conducted a cross-sectional study in the antenatal clinic of an urban primary health center, run by the government of National Capital Territory, Delhi and located in an urban resettlement colony in the North-East district of the state from December 2018 to April 2019. The area was selected as it constitutes the field practice area of a government medical college in the city. The antenatal clinic is conducted once a week and provides antenatal care services to around 500 pregnant women annually, mostly residents of the area. Service delivery is through a team of resident doctors, medical interns, two public health nurses, and a government medical officer.

Standard care

All the pregnant women attending the clinic are prescribing only folic-acid during the first trimester of their pregnancy. From the second-trimester onward, the women are prescribed iron-folic acid (IFA) tablets containing 100 mg elemental iron and 500 μg folic acid. The IFA tablets were provided free of cost to all the beneficiaries at the health facility. Women without anemia (Hb ≥11 g) were prescribed once daily IFA tablet while those with anemia (Hb <11 g) were being prescribed twice daily IFA tablet. Women detected with severe anemia (Hb <8 g) were referred to a higher center to provide for specialist obstetrics care.

Selection criteria

We included all adult pregnant women with ≥16 weeks amenorrhea attending the antenatal clinic. We excluded those women who were previously detected having severe anemia, anemic women on parenteral iron therapy or those who received blood transfusion during their current pregnancy and finally those anemic women who were previously diagnosed with non-IDA.

Sample size and sampling strategy

At 95% confidence level, 7% margin of error, with expected prevalence of IFA adherence being 52%,[6] and accounting for 10% non-response, the sample size was estimated to be 215. We selected the participants applying the consecutive sampling method, i.e., all the women meeting the selection criteria and willing to participate were enrolled into the study, one after the other, until a maximum of 10 women had been enrolled in a single session.


We interviewed the women using a patient interview schedule. We collected information on sociodemographic variables, knowledge, attitude and adherence practices relating to the participant's IFAS intake. We determined the drug adherence rates in the previous seven days, by dividing the ([total number of IFA tablets prescribed–total number of missed IFA tablet doses]/[total number of IFA tablets prescribed]) × 100.

Standard definitions

IFAS adherent status was defined as women taking ≥80% of their prescribed IFAS in the previous 7 days, equivalent to IFAS intake for at least 6 days in the previous week. We estimated the adequacy of drug stocks present with the women by calculating the proportion of days with IFA coverage in the last 30 days and classifying it as adequate if drug coverage was ≥90%. Among the women who were non-adherent to their prescribed IFAS, we also ascertained the reasons for medication non-adherence. Furthermore, we obtained participants perspectives relating to IFA intake through means of in-depth interviews in 10 women with moderate anemia (HbA1c 8–10 g%).

Statistical analysis

We analyzed the data using IBM SPSS Statistics for Windows, Version 25.0. (Armonk, NY: IBM Corp). Data were expressed in frequency and proportions. Chi-square test was used to find an association between categorical variables. A P < 0.05 was considered as statistically significant.


The study was approved and exempted from full review by the Institutional Ethics Committee of the medical college. We collected data from the women after obtaining their written and informed consent. All the women were provided health education relating to anemia, the need for IFAS and its good adherence through individual counseling after the interviews.

  Results Top


We enrolled a total of 211 pregnant women with 100% response rate. The mean (±standard deviation) age of the women was 24.6 (±3.4) years, ranging from 19 to 35 years. The median years of education of the women were 11 years. All the women were currently married. All the women had received at least two antenatal visits at the time of enrolment into the study. One hundred and three (48.8%) women were primigravida, while 122 (57.8%) did not have any previous children.

Iron-folic acid supplementation adherence

The IFA tablets were prescribed once daily to 173 (82%) women that were nonanemic and twice daily to 38 (18%) women who were anemic. A total of 54 (25.6) women reported being nonadherent to their prescribed IFA medication in the previous 7 days. There were also 50 (23.7%) women who did not take their IFAS on the last day. One hundred and seventy-five (83%) women had adequate IFAS stocks during the last 30 days.

Thirty-four women took their IFA pills before their meals, six took it with their meals while the rest took it appropriately after their meals.

Reasons for non-adherence to IFAS were reported by the women to be forgetfulness 43 (20.4%), side-effects 7 (3.3%) and running out of IFA pill stocks 28 (13.2%).

The importance of high adherence to IFAS during pregnancy was perceived to be very important by 102 (48.3%), quite important by 66 (31.3%), important by 24 (11.4%), somewhat important by 10 (4.7%), and not at all important by 9 (4.2%) women.

None of the sociodemographic and clinical variables was found to be significantly associated with nonadherence to IFAS on either bivariate or adjusted analysis [Table 1]. However, women reporting inadequate IFAS stocks at home in the previous month were three times more likely to be nonadherent to IFAS compared to the women having adequate IFAS coverage (P = 0.004).
Table 1: Iron-folic acid supplementation adherence in antenatal women in Delhi (n=211)

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Perspectives of women having moderate anemia during pregnancy was favorably inclined toward IFAS intake, which indicated their perception of increased susceptibility to adverse health outcomes in case of nonadherence. A respondent replied, “the IFA pills are useful during pregnancy…they protect my health…. I take them regularly.” However, there were four primigravida women who reported never having previously received IFA either through frontline health workers or at school; “we have never been given iron pills before our pregnancy.” None of these women had been previously diagnosed with anemia by any medical practitioner either.

  Discussion Top

Adherence to IFAS in pregnant women can safeguard them against nutritional anemia and the related adverse pregnancy outcomes. The present study revealed that nearly one in four pregnant women were nonadherent to their IFA medication, while nearly one in five women lacked adequate IFA stocks. However, the rates of IFAS adherence among antenatal women observed in our study are significantly higher compared to those reported by some recent studies conducted in Africa.[11],[12],[13],[14] Another study in an urban area of Southern India by Mithra et al. found 64.7% adherence to IFAS.[15] The improved adherence rates in our study are probably due to urbanization and better healthcare access due to the central location of the health facility near a busy marketplace. Nevertheless, the definition of IFAS nonadherence employed by the different researchers indicates considerable methodological heterogeneity due to which the outcomes in terms of IFAS adherence rates may not be comparable across studies.

In this study, none of the sociodemographic and birth variables was associated with nonadherence to IFAS. Previous studies have, however, indicated these variables influencing IFAS adherence.[14],[15] Our results are probably due to the homogeneous population of the study area and the improved service quality blunting the detrimental effect of adverse sociodemographic parameters.

We found running out of IFA pill stocks was a significant predictor of nonadherence in the present study, which could be either due to missed appointments, dispensing of inadequate IFAS or drug stock-outs at the health facility. Similarly, a previous study conducted in the urban slums of Delhi also observed high antenatal care coverage but the delivery of an inadequate ANC package to the beneficiaries.[16] The study by Varghese et al. in a North Indian state also attributed low intake of IFAS by pregnant women due to them having low stocks.[17]

Dyspepsia and gastritis are frequent side-effects of IFAS that can result in lower adherence.[15] However, in this study, this was reported by very few women, which probably occurred, since the majority of women were taking their IFAS appropriately after their meals. Another study in Northern India also reported that nonconsumption of IFAS by pregnant women was not due to the perceived side-effects of the drug.[17]

There are certain limitations to the study. First, the cross-sectional study design precluded the possibility of detecting any change in IFAS adherence prospectively during the course of the women's pregnancy. Second, it was a clinic-based study which limits its generalizability to other antenatal women in the community who did not report to the health facility. Third, although IFAS was provided at the health facility, we did not assess the drug inventory control methods at the health center, which in case of poor stock control could result in the incomplete dispensing of the prescribed drugs. We also did not collect data pertaining to missed or delayed appointments among the women. Both these factors resulting in nonreplenishment of IFA drug stocks could cause nonadherence in case of the women failed to procure the drugs from alternative sources or through out-of-pocket purchase. Fourth, the possibility of the participants over-reporting their drug adherence due to any social-desirability bias cannot be ruled out.[18]

  Conclusion Top

The present study indicates that adherence to IFAS among pregnant women is suboptimal and often results from them running out of drug-stocks. Ensuring IFAS coverage for the women through regular home delivery of IFAS by frontline health workers may be beneficial in this regard. Furthermore, since, forgetfulness is a major reason for IFAS nonadherence, the utilization of modern tools such as mHealth/eHealth and digital technology for the provision of effective reminders promoting IFAS adherence also warrants exploration.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. The Global Prevalence of Anaemia in 2011. Geneva: World Health Organization; 2015.  Back to cited text no. 1
McLean E, Cogswell M, Egli I, Wojdyla D, de Benoist B. Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993-2005. Public Health Nutr 2009;12:444-54.  Back to cited text no. 2
World Health Organization The world health report 2002—reducing risks, promoting healthy life. World Health Organization; 2002.  Back to cited text no. 3
World Health Organization. Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity. Vitamin and Mineral Nutrition Information System. Geneva: World Health Organization; 2011 (WHO/NMH/NHD/MNM/11.1). Available from: http://www.who.int/vmnis/indicators/haemoglobin.pdf. [Last accessed on 2019 May 25].  Back to cited text no. 4
Anand T, Rahi M, Sharma P, Ingle GK. Issues in prevention of iron deficiency anemia in India. Nutrition 2014;30:764-70.  Back to cited text no. 5
International Institute for Population Sciences and ICF. National Family Health Survey (NFHS-4), 2015-16: India. Mumbai: International Institute for Population Sciences; 2017.  Back to cited text no. 6
Di Renzo GC, Spano F, Giardina I, Brillo E, Clerici G, Roura LC. Iron deficiency anemia in pregnancy. Women's Health 2015;11:891-900.  Back to cited text no. 7
Balarajan Y, Ramakrishnan U, Ozaltin E, Shankar AH, Subramanian SV. Anaemia in low-income and middle-income countries. Lancet 2011;378:2123-35.  Back to cited text no. 8
Sharma JB, Shankar M. Anaemia in pregnancy. Differential Diagnosis in Obstetrics and Gynaecology: JIMSA 2008;23:253-60. Available from: http://medind.nic.in/jav/t10/i4/javt10i4p253.pdf. [Last accessed on 2019 May 25].  Back to cited text no. 9
National Iron Plus Initiative for Anaemia Control. Government of India. Available from: http://www.nrhmhp.gov.in/sites/default/files/files/Iron%20plus%20initiative%20for%206%20months%20-5%20years.pdf. [Last accessed on 2019 May 25].  Back to cited text no. 10
Niguse W, Murugan R. Determinants of adherence to iron folic acid supplementation among pregnant women attending antenatal clinic in Asella town, Ethiopia. Int J Ther Appl 2018;35:60-7. Available from: http://journal.npaa.in/admin/ufile/1523794880IJTA460.pdf. [Last accessed on 2019 May 25].  Back to cited text no. 11
Kiwanuka TS, Ononge S, Kiondo P, Namusoke F. Adherence to iron supplements among women receiving antenatal care at Mulago National Referral Hospital, Uganda-cross-sectional study. BMC Res Notes 2017;10:510.  Back to cited text no. 12
Kamau MW, Mirie W, Kimani S. Compliance with Iron and folic acid supplementation (IFAS) and associated factors among pregnant women: Results from a cross-sectional study in Kiambu County, Kenya. BMC Public Health 2018;18:580.  Back to cited text no. 13
Gebremariam AD, Tiruneh SA, Abate BA, Engidaw MT, Asnakew DT. Adherence to iron with folic acid supplementation and its associated factors among pregnant women attending antenatal care follow up at Debre Tabor General Hospital, Ethiopia, 2017. PLoS One 2019;14:e0210086.  Back to cited text no. 14
Mithra P, Unnikrishnan B, Rekha T, Nithin K, Mohan K, Kulkarni V, et al. Compliance with iron-folic acid (IFA) therapy among pregnant women in an urban area of south India. Afr Health Sci 2013;13:880-5.  Back to cited text no. 15
Ghosh-Jerath S, Devasenapathy N, Singh A, Shankar A, Zodpey S. Ante natal care (ANC) utilization, dietary practices and nutritional outcomes in pregnant and recently delivered women in urban slums of Delhi, India: An exploratory cross-sectional study. Reprod Health 2015;12:20.  Back to cited text no. 16
Varghese JS, Swaminathan S, Kurpad AV, Thomas T. Demand and supply factors of iron-folic acid supplementation and its association with anaemia in North Indian pregnant women. PLoS One 2019;14:e0210634.  Back to cited text no. 17
Basu S, Garg S, Sharma N, Singh MM. Improving the assessment of medication adherence: Challenges and considerations with a focus on low-resource settings. Ci Ji Yi Xue Za Zhi 2019;31:73-80.  Back to cited text no. 18


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