Ethiopian women's perspectives on antenatal care and iron‐folic acid supplementation: Insights for translating global antenatal calcium guidelines into practice

Abstract

After decades of global response to iron-deficiency anemia, lessons learned from antenatal iron-folic acid (IFA) supplementation can inform new micronutrient supplementation efforts. The World Health Organization recommends calcium supplementation for the prevention of preeclampsia; however, little is documented on how to design programs to integrate calcium into the standard of care. Twenty interviews with pregnant women and 22 interviews with health providers and volunteers in two districts in Ethiopia were conducted to examine how barriers and facilitators to antenatal care, IFA supplementation, and initial reactions to calcium supplements and regimen might influence adherence and inform future programs. Women viewed supplementation positively but cited lack of information on benefits and risks, forgetfulness, and inconsistent IFA supply as challenges. Though knowledge and awareness of anemia and IFA supplements were widespread, preeclampsia was mostly unknown. Some symptoms of preeclampsia were viewed as normal in pregnancy, making it difficult to convey risk to motivate supplement use. Some women viewed co-consumption of IFA and calcium as potentially harmful and were confused regarding the simultaneous risks of anemia and hypertension, understood as "low" and "high" blood levels in pregnancy. However, most said they would take both IFA and calcium supplements if provided with supplements and counseling on purpose and benefits. Strategies such as social support from families, stronger community-based counseling, and increased health care provider and community awareness of preeclampsia are critical for women to understand the benefits of supplementation and resolve confusion caused by current descriptors used for anemia and hypertension.

Maternal nutrition practices in Uttar Pradesh, India: Role of key influential demand and supply factors

“…Although this is below the recommended levels, it is substantially better than the current situation (approximately 40 IFA tablets are consumed during pregnancy). Our findings align well with existing literature from Bihar, Pakistan, Indonesia, and Kenya related to associations of maternal knowledge and family support in ensuring sustained IFA adherence (Birhanu et al, ; Wiradnyani, Khusun, Achadi, Ocviyanti, & Shankar, ). Prior research also highlights the role of education and wealth for compliance to IFA recommendations (Nisar, Dibley, & Mir, ; Wendt et al, ).…”

“…In comparison to IFA compliance, much less is known globally about barriers and facilitators related to calcium consumption. Qualitative findings from Ethiopia and Kenya suggest that awareness of risks and benefits of calcium along with family support were critical in attaining sustained adherence (Birhanu et al, ; Martin et al, ; Martin et al, ). Lack of awareness of preeclampsia/eclampsia and apprehensions around coconsumption of IFA and calcium were identified as key demand‐side barriers in these contexts (Birhanu et al, ), which provides pertinent guidance for structuring counselling messages..…”

“…Qualitative findings from Ethiopia and Kenya suggest that awareness of risks and benefits of calcium along with family support were critical in attaining sustained adherence (Birhanu et al, 2018;. Lack of awareness of preeclampsia/eclampsia and apprehensions around coconsumption of IFA and calcium were identified as key demand-side barriers in these contexts (Birhanu et al, 2018), which provides pertinent guidance for structuring counselling messages.. Similar to IFA, a key limiting factor will be availability and accessibility of calcium supplements.…”

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

“…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.…”

“…It was a major concern for all the three categories of study participants since it had never happened before. Stock-outs [54,55] and inconsistent IFAS supply [53] have been cited as a challenge and foremost barrier to effective IFAS use. Through this approach, a demand for IFAS was created which could not be met by existing resources.…”