IFA compliance and associated factors among postpartum mothers: a cross-sectional analytical study at public health facilities in Bharatpur metropolitan city, Chitwan Nepal
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* Sahera Khatun
* Jiwan Kumar Poudyal
* Sumitra Parajuli
* Govinda Prasad Dhungana

## Abstract

**Objectives** Iron deficiency anaemia and inadequate compliance with iron–folic acid (IFA) supplementation among pregnant and postpartum women pose substantial public health challenges in Nepal. Hence, this study aimed to determine IFA compliance and identify associated factors among postpartum mothers in Bharatpur Metropolitan City, Chitwan, Nepal.

**Design** An analytical cross-sectional design was employed.

**Setting** This study was conducted in Bharatpur Metropolitan City, Chitwan, Nepal.

**Participants** A total of 286 postpartum mothers were selected using non-probability purposive sampling. Ethical approval was obtained from the Institutional Review Committee of Shree Medical and Technical College, and informed consent was obtained from all participants before data collection. Semi-structured questionnaires were administered through face-to-face interviews to collect data and ensure an in-depth understanding of the participants’ responses.

**Results** Among the 286 participants, 53.5% demonstrated compliance with the IFAs. Multivariable logistic regression showed that compliance was significantly and positively linked to the level of education ((AOR)=3.629; 95% CI: (1.438 to 9.153)) and knowledge regarding IFAs (AOR=3.751; 95% CI: (2.145 to 6.562)). The reasons for non-compliance included the consumption of too many tablets, lack of information provided by healthcare workers, experiencing side effects and forgetting to take the tablets.

**Conclusions** IFA compliance was observed in more than half of the participants. Compliance was influenced by participants’ education and knowledge. The authors hold a strong conviction that relevant authorities can provide the necessary education in specific areas of concern to enhance the design and improvement of IFA programme strategies.

*   Cross-Sectional Studies
*   EPIDEMIOLOGIC STUDIES
*   NUTRITION & DIETETICS

### STRENGTHS AND LIMITATIONS OF THIS STUDY

*   It used a cross-sectional analytical design with a well-defined sample.

*   This study used inferential methods and logistic regression to strengthen the findings.

*   The study was conducted in selected public health facilities, which may have limited the generalisability of the findings due to the exclusion of private-sector facilities.

*   Recall bias may have led participants to overestimate or underestimate their knowledge of daily iron–folic acid supplementation.

## Introduction

Pregnancy exerts a substantial impact on both maternal well-being and offspring. The augmented requisites of iron–folic acid (IFA) supplementation during gestation play a pivotal role in mitigating risks to both maternal and neonatal health, particularly in preventing maternal iron deficiency anaemia (IDA) and the concomitant risk of low birth weight.1 2 IDA is a significant global public health problem, affecting pregnant women,3–6 postpartum women and children alike.7 8 To address this issue, the WHO has advised daily oral folic acid supplementation with 30 mg to 60 mg of elemental iron and 400 µg (0.4 mg) of folic acid during pregnancy to prevent maternal anaemia, puerperal sepsis, low birth weight and preterm birth.9 To address IDA, the Government of Nepal has been providing IFA to pregnant and postpartum women since 1998 and recommended that they consume the supplements for 225 days starting from their second trimester.10

Globally, anaemia affected 46% of pregnant women in 2016 and accounted for 20% of all maternal deaths.11 Every year, 115 000 maternal and 591 000 prenatal deaths occur due to IDA.12 13 The WHO issued a target to reduce anaemia among women of reproductive age by 50% by 2025.14 15 The targets within the WHO’s Sustainable Development Goal 2 (SDG-2) are aimed at reducing various forms of malnutrition among children under 5 years old, pregnant women, lactating mothers, adolescent girls and older individuals.16 IDA is a serious public health issue in South and Southeast Asia where 52% of pregnant mothers are still suffering from the condition.11 Evidence suggests that IFA during pregnancy reduces the incidence of anaemia.17

In Nepal, health workers have been actively addressing the problem of IDA; however, it remains a significant challenge. This health condition is manifested in different ways across the country and influenced by factors like politics and geography.10 18 Health sector or client-related factors are the main reason for poor IFA compliance in developing countries.19 IDA is one of the major nutritional concerns in Nepal.12 Several interventional activities have been implemented to combat the problem, but its status has not been improved13 20 due to IFA non-compliance.18 Although increasing IFA has been a top priority programme in Nepal, the prevalence of IDA remains high.13 21 Bharatpur Metropolitan City has a sufficient number of health facilities, but it has higher IFA non-compliance compared with the national level.22 This finding highlights the existence of a research gap necessitating comprehensive investigation. Hence, this study aimed to identify IFA compliance and associated factors among postpartum mothers attending public health facilities in Bharatpur Metropolitan City (figure 1).

![Figure 1](http://bmjopen.bmj.com/https://bmjopen.bmj.com/content/bmjopen/15/3/e087459/F1.medium.gif)

[Figure 1](http://bmjopen.bmj.com/content/15/3/e087459/F1)

Figure 1 
Factors associated with iron and folic acid supplementation compliance. IFA, iron–folic acid supplementation.

## Materials and methods

### Research design and study area

This institution-based, analytical, cross-sectional study was conducted with 286 postpartum mothers from December 2021 to August 2022. Participants were recruited from one Maternal and Child Health (MCH) clinic, one primary healthcare centre, eight health posts and two basic health service centres recognised as public health facilities in Bharatpur Metropolitan City, Chitwan. These facilities were equipped to provide basic health services aimed at enhancing community well-being and preventing the spread of disease.

### Sampling and sample size

A non-probability purposive sampling technique was used to select postpartum mothers attending these health facilities for their child’s first diphtheria, pertussis and tetanus (DPT) vaccine. However, mothers who were unwilling or unable to respond and caregivers who responded on behalf of the mothers were excluded from the study. The sample size was determined using the Cochran formula,23 ((n)=z2pq/d2), with a 95% CI, an estimated prevalence of 42%18 based on prior research, and an allowable error of 6.0%. This calculation yielded an initial sample size of 260, which was later adjusted to 286 after estimating a 10% non-response rate.

### Patient and public involvement

The study population was involved in the study from the start, and their perspectives on the importance of IFA compliance information were gathered. The research questions were developed with response from the study population and finalised following pretesting. Participation was voluntary and respondents were informed of their right to withdraw from the interview at any time.

### Data collection technique

The data collection process was conducted by the researcher from 23 March 2022 to 24 April 2022. Data were collected using a semi-structured questionnaire comprising six distinct sections. These sections covered sociodemographic information, obstetric and postnatal care, knowledge of IFA, consumption patterns and reasons for IFA compliance and non-compliance. Participants’ knowledge was assessed regarding the identification of preventable diseases associated with the intake of IFA, determination of available sources, initiation and duration of IFA tablet consumption, quantity of supplements consumed during the antenatal and postnatal periods and awareness of side effects. A scoring system was employed, with correct responses scored as 1 and non-responses or incorrect responses scored as 0. Finally, the summative scores were categorised as poor or good knowledge.24 IFA compliance was assessed based on participant compliance with the prescribed dosage and intake regimen, as reported during the data collection process.

### Reliability, validity and ethical clearance

To ensure comprehensibility, consistency and validity, the questionnaire was initially developed in English, translated into Nepali, and then back-translated into English by a university lecturer. Pretesting involving 10% of the sample size (ie, 29 participants) was conducted at an MCH clinic, leading to necessary refinements by the researcher.

Before data collection, the research objectives were thoroughly explained and written informed consent was obtained from each participant. The principles of privacy, confidentiality and anonymity were strictly adhered to, granting participants autonomy to decline participation or withdraw from the study at any point. The study was approved by the Institutional Review Committee of Shree Medical and Technical College (SMTC-IRC) (Reference: SMTC-IRC-20220214–92), and proper permission to conduct the study was acquired from the relevant authorities.

### Data analysis plan

Following data collection, a meticulous process of data entry, cleaning and validation was performed to ensure the accuracy and reliability of the data. The SPSS Version 26 software was used for subsequent analysis. Descriptive statistical techniques, such as frequencies, percentages, means and SD, were used along with inferential methods, including χ2, Fisher’s exact tests and bivariate and multivariable logistic regression analyses, to derive meaningful conclusions from the collected data.

## Results

### Demographic, obstetric and postnatal related characteristics

Among the 286 participants, most participants were Hindus (82.2%) and belonged to joint families (62.2%). Almost all participants (97.9%) were literate and 59.4% were engaged in household work (table 1).

View this table:
[Table 1](http://bmjopen.bmj.com/content/15/3/e087459/T1)

Table 1 
Sociodemographic findings (n=286)

More than half of the participants were multigravida (54.5%) or primiparous (55.6%). Almost all participants (98.6%) visited health facilities for antenatal care (ANC), whereas 93.0% visited health facilities for postnatal check-ups (PNC). Among those who visited health facilities for ANC checkups, 63.5% visited government health facilities. Additionally, 17.1% reported a history of abortion, and a high percentage of mothers delivered their babies in a government health facility (82.5%) with the majority having normal deliveries (68.5%) (table 2).

View this table:
[Table 2](http://bmjopen.bmj.com/content/15/3/e087459/T2)

Table 2 
Obstetric and PNC-related characteristics of respondents (n=286)

### IFA compliance

The study revealed that 53.5% (95% CI: 47.8 to 59.2) of participants complied with the recommended IFA (ie, they consumed the recommended dose of 225 tablets) during the pregnancy and postpartum period (figure 2).

![Figure 2](http://bmjopen.bmj.com/https://bmjopen.bmj.com/content/bmjopen/15/3/e087459/F2.medium.gif)

[Figure 2](http://bmjopen.bmj.com/content/15/3/e087459/F2)

Figure 2 
Proportion of compliance and non-compliance of intake of IFA tablets. IFA, iron–folic acid supplementation.

The primary factors contributing to IFA compliance included proper counselling by healthcare professionals (65.4%), awareness of the associated benefits (82.4%), understanding anaemia prevention (51.6%), support from family members (43.1%) and availability of cost-free tablets (42.5%). In contrast, the reasons for non-compliance included concerns about consuming too many tablets (35.3%), lack of information provided by healthcare workers (34.6%), experiencing side effects (24.8%) and forgetting to take the tablets (21.1%).

Furthermore, nearly all participants (99.0%) adhered to the recommended IFA during pregnancy. Most (98.5%) commenced IFA on the first day of the second trimester, and approximately half (54.1%) continued until day 45 of the postnatal period. Most participants (82.3%) took IFA before bedtime, and 63.3% reported side effects, notably black stools. However, only a minority (20.0%) sought assistance from healthcare facilities to address these adverse effects (table 3).

View this table:
[Table 3](http://bmjopen.bmj.com/content/15/3/e087459/T3)

Table 3 
Consumption of IFA and its side effects (n=286)

Participants’ knowledge was assessed regarding the identification of preventable diseases associated with IFA, identification of accessible sources of IFA, initiation and duration of IFA, quantity of IFA throughout the antenatal and postnatal phases and awareness of associated side effects. The findings revealed that 56.3% of the respondents displayed good knowledge, whereas the remaining 43.7% exhibited poor knowledge.

### Factors associated with compliance with IFA among postpartum mothers

A significant association was observed between IFA compliance and several key factors. A significant association was revealed between IFA compliance and ethnicity (p=0.003), education level (p<0.001), occupation (p=0.019), frequency of ANC visits (p=0.036), knowledge level (p<0.001) and initiation of IFA (p<0.001). Moreover, individuals in the Brahmin/Chetteri ethnic group exhibited the highest compliance (64.8%). Among those receiving services, 70% demonstrated compliance. Additionally, compliance increased with higher levels of education. In addition, participants who received ANC four or more times had significantly higher IFA compliance (56.1%) (p=0.036). Likewise, 68.6% of those with good knowledge demonstrated IFA compliance, whereas 56.5% of those who initiated consumption of IFA at 4 months of gestation demonstrated compliance (table 4).

View this table:
[Table 4](http://bmjopen.bmj.com/content/15/3/e087459/T4)

Table 4 
Factors associated with IFA compliance

### Multivariable analysis of IFA compliance among postpartum mothers

The study employed both bivariate and multivariable logistic regression analyses to achieve its research objectives. In the bivariate analysis, all factors were assessed; among them, only eight demonstrated statistically significant associations with compliance. These significant variables, with a p value <0.10, were subsequently entered into multivariable logistic regression analysis.

In the multivariate analysis, the Nagelkerke R2 value indicated that approximately 26.0% of the variability in IFA compliance was explained by factors associated with the model. Additionally, the Hosmer–Lemeshow test yielded a value of 0.178, implying that the model exhibited a good fit for prediction purposes.

In the multivariate logistic regression analysis, two predictors emerged as significantly associated with IFA compliance. The multivariable analysis indicated that participants who had higher secondary and above-level education were 3.629 times more likely to comply than those with basic education and below (AOR=3.629; 95% CI: (1.438 to 9.153)), and those who had good knowledge about IFA were 3.751 times more likely to comply than those who had poor knowledge (AOR=3.751; 95% CI: (2.145 to 6.562) (table 5).

View this table:
[Table 5](http://bmjopen.bmj.com/content/15/3/e087459/T5)

Table 5 
Multivariable analysis of factors affecting IFA compliance

## Discussion

The current study revealed that more than half of the participants complied with IFA while approximately half of them showed non-compliance. This trend was consistent with studies conducted in Ethiopia,5 24 25 Southern Senegal26 and Nepal.12 21 In contrast, compliance in the current study was higher than that in other studies from Ethiopia,7 8 27 28 Tanzania29 and Kenya,19 possibly due to variations in socioeconomic status, timeframes, health-seeking behaviours, knowledge levels, healthcare service quality and counselling.

In this study, knowledge about IFA benefits and health worker counselling emerged as key factors associated with high compliance, aligning with studies from Ethiopia.7 25 Notably, compliance was considerably higher than that in the study conducted in Kathmandu, Nepal.30 Nevertheless, a substantial proportion of participants cited excessive tablet consumption as a reason for non-compliance, which contrasted with findings from Ethiopia3 25 31 and Nepal.30

This study showed that participant ethnicity was significantly associated with IFA compliance: mothers of the Brahmin/Chetteri ethnicity were three times more likely to comply with IFA than those of the Dalit ethnicity, which was similar to the findings of a study conducted in Pokhara, Nepal.12 The results of the analysis suggested that individuals of Brahmin/Chetteri ethnicity exhibit higher levels of education, which may have contributed to this finding.

Similarly, educational level showed a significant association with IFA compliance, and those who had higher secondary and above-level education were three times more likely to comply with IFA than respondents who had a basic level and below. This finding is in line with a study conducted in Ethiopia.3 7 A possible explanation is that education may enhance women’s awareness of micronutrient deficiencies, methods to address them, understanding IDA risk during pregnancy, benefits of consuming IFA for both the mother and fetus and compliance with IFA intake during pregnancy.

Likewise, the occupation of participants was significantly associated with IFA compliance, and those who were employed in service work were two times more likely to comply with IFA than those who were homemakers, which was consistent with the findings of a study conducted in Sri Lanka.32 One possible explanation is that women involved in service work may have better access to health information due to their exposure to workplace wellness programmes, health insurance benefits, colleague interactions and financial independence to purchase supplements.

The number of antenatal care visits was significantly associated with IFA compliance; those with≥4 visits were twice as likely to comply compared with those with<4 visits, consistent with a study conducted in Ethiopia.4 27 31 A possible explanation is that pregnant women may receive guidance from healthcare professionals on the benefits of IFA, compliance encouragement and the risks of non-compliance to both the mother and fetus.

Finally, strong knowledge about IFA was significantly correlated with compliance, as those who were well informed were three times more likely to comply, aligning with findings from Tanzania29 and Ethiopia.4 5 24 27 33 The primary factor contributing to this compliance may be the elevated level of participant knowledge, which correlated with their educational attainment.

### Conclusion

In this study, 53.5% of the participants were compliant with IFA recommendations. The results revealed that higher secondary education and higher education levels were strongly associated with greater IFA compliance. Importantly, the findings reinforce the critical connection between knowledge and compliance, as participants with good knowledge of IFAs exhibited notably higher compliance. We hold a strong conviction that relevant authorities can provide the necessary education in specific areas of concern to enhance the design and improvement of IFA programme strategies.

### Limitations of the study

The cross-sectional analytical design of this study limits the ability to draw causal inferences. Additionally, focusing on public-sector health facilities restricts the generalisability of the findings to private-sector facilities and community settings. Moreover, the inclusion of postpartum mothers attending their child’s first DPT vaccination introduces the potential for recall bias regarding IFA compliance during pregnancy and postpartum. Finally, the reliance on self-reported data to assess compliance may introduce uncertainty and affect the accuracy of the results.

### Practical implication, recommendation and future research

Despite these limitations, this study has several programmatic implications. First, we provide baseline information on the compliance rates for IFA in the Chitwan District of Nepal. Second, we identify the factors associated with IFA compliance. Third, we identify the reasons for IFA non-compliance.

The Government of Nepal has implemented several programmes to improve the intake of iron and folic acid among pregnant and postpartum women, such as the Intensification of Maternal and Neonatal Micronutrient Programme, National Strategy for the Control of Anaemia in Women and Children and Iron Supplementation Programme. We recommend that concerned authorities update the information used to design IFA programme policies and strategies.

We also recommend conducting large-scale, comprehensive and well-designed studies on IFA compliance in private health facilities and rural communities in Nepal, where compliance may present an unseen programmatic challenge to improving MCH.

### Supplementary data

[[bmjopen-2024-087459supp001.pdf]](pending:yes)

## Data availability statement

Data are available upon reasonable request. Data is not uploaded within the article but will be available on request.

## Ethics statements

### Patient consent for publication

Consent obtained directly from patient(s).

### Ethics approval

This study involves human participants and was approved by Shree Medical and Technical College-Institutional Review Committee (SMTC-IRC) Registration no: SMTC-IRC-20220214-92. Participants gave informed consent to participate in the study before taking part.

## Footnotes

*   Contributors JKP is responsible for the overall content as a guarantor. SK and JKP developed the conceptualisation of the idea; SK collected the data; SP monitored and supported data collection; and GPD analysed the data. Finally, all authors contributed to writing the original draft, validation and editing of the final manuscript. Moreover, all authors equal responsibility for the revision draft of the manuscript.

*   Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

*   Competing interests None declared.

*   Patient and public involvement Patients and/or the public were involved in the design, conduct, reporting or dissemination plans of this research. Refer to the Methods section for further details.

*   Provenance and peer review Not commissioned; externally peer reviewed.

*   Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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