Community-based distribution of iron–folic acid supplementation in low- and middle-income countries: a review of evidence and programme implications

Abstract

Objective: The present literature review aimed to review the evidence for community-based distribution (CBD) of iron-folic acid (IFA) supplementation as a feasible approach to improve anaemia rates in low-and middle-income countries. Design: The literature review included peer-reviewed studies and grey literature from PubMed, Cochrane Library, LILAC and Scopus databases. Setting: Low-and middle-income countries. Subjects: Non-pregnant women, pregnant women, and girls. Results: CBD programmes had moderate success with midwives and community health workers (CHW) who counselled on health benefits and compliance with IFA supplementation. CHW were more likely to identify and reach a greater number of women earlier in pregnancy, as women tended to present late to antenatal care. CBD channels had greater consistency in terms of adequate supplies of IFA in comparison to clinics and vendors, who faced stock outages. Targeting women of reproductive age through school and community settings showed high compliance and demonstrated reductions in anaemia. Conclusions: CBD of IFA supplementation can be a valuable platform for improving knowledge about anaemia, addressing compliance and temporary side-effects of IFA supplements, and increasing access and coverage of IFA supplementation. Programmatic efforts focusing on community-based platforms should complement services and information provided at the health facility level. Provision of training and supportive supervision for CHW on how to counsel women on benefits, side-effects, and when, why, and how to take IFA supplements, as part of behaviour change communication, can be strengthened, alongside logistics and supply systems to ensure consistent supplies of IFA tablets at both the facility and community levels. Globally, anaemia affects 29 % of pregnant women and 38 % of non-pregnant women (1) and is associated with one-fifth of maternal deaths (2) . Anaemia puts women at greater risk of mortality, morbidity, postpartum haemorrhage and poor birth outcomes, including preterm births and low birth weight (3,4) . The WHO recommends daily iron-folic acid (IFA) supplementation (30-60 mg iron, 0·4 g folic acid) initiated as early as possible and continued throughout pregnancy for all adolescent and adult women as a key intervention to reduce the risk of maternal anaemia, iron deficiency and infants born with low birth weight (5) . According to findings from a recent meta-analysis, IFA supplementation would increase the mean blood Hb concentration by 10·2 (95% CI 6·1, 14·2) g/l in pregnant women and by 8·6 (95% CI 3·9, 13·4) g/l in non-pregnant women (aged 19-21 years) (6) . Applying these shifts to estimated blood Hb concentrations indicates that about 50 % of anaemia in women could be eliminated by IFA supplementation (6) .

Effectiveness of programme approaches to improve the coverage of maternal nutrition interventions in South Asia

“…These enablers confirm previous findings on IFA supplementation that point to the role of women's knowledge and empowerment, household resources, women's access health services, and the quality of health services in determining whether women receive and consume supplements and adopt positive dietary practices (Kavle & Landry, 2017;Kavle & Landry, 2018;Siekmans, Roche, Kung'u, Desrochers, & De-Regil, 2017;Sununtnasuk, D'Agostino, & Fiedler, 2016).…”

“…A recent review of global evidence found that community-based distribution of IFA supplements provides an effective platform to improve knowledge about anaemia, provide counselling to improve compliance, and should be coupled with actions to ensure the consistent supply of supplements at facility and community levels to improve both access and coverage (Kavle & Landry, 2018). In addition, a separate review highlighted the importance of tailored, culturally appropriate nutrition education and counselling during pregnancy (Kavle & Landry, 2018). Asia is very small, and greater investments in implementation research and evaluations are needed to enhance the understanding of the barriers, enablers, and pathways to increasing coverage across programmes and diverse contexts in the region.…”

Time for change is now: Experiences of participants in a community-based approach for iron and folic acid supplementation in a rural county in Kenya, a qualitative study

“…These findings are consistent with literature on strengths of community based distribution of IFAS as a valuable platform in implementation of IFAS programmes [34]. The study participants found this approach beneficial to not only the pregnant women but also to all stakeholders and the entire community.…”

“…Counselling enables clients to gain understanding to take initiative and create demand for services. Formative research studies have emphasized the need for community-based counselling [34,52,53]. Nurses in this study confessed providing inadequate IFAS counselling.…”

Effect of a community-based approach of iron and folic acid supplementation on compliance by pregnant women in Kiambu County, Kenya: A quasi-experimental study

“…If not addressed, anaemia, can eventually cause maternal, foetal and infant death. Globally, 1 out of 5 maternal deaths are associated with anaemia [7]. In Kenya, anaemia in pregnancy is associated with estimated 1 in 5 perinatal deaths and 1 in 10 maternal deaths respectively [8].…”