The Role of Health Facilities in Supporting Adherence to Iron-folic Acid in Haiti and Malawi: A Study Linking Health Facility Survey and Population Survey Data

Abstract

Background: Iron-folic acid (IFA) supplementation during pregnancy is key to prevent maternal anemia. In Malawi and Haiti, consumption of IFA supplements remains suboptimal. This study examined the IFA-related services provided in health facilities and their association with women’s adherence to IFA supplementation during pregnancy.Methods: This study used data from the Demographic and Health surveys (DHS) and the Service Provision Assessment (SPA) in Haiti and Malawi. Using GPS data collected in both surveys, each DHS cluster was linked to health facilities surveyed in the SPA within a specified buffer distance (5 km for urban areas and 10 km for rural areas). IFA-related services were examined for health facilities within the buffer, including the availability of IFA supplements, prescription of IFA, and client counseling on IFA. Adherence to IFA supplementation was examined for women who received antenatal care (ANC) for their most recent live birth in the 2 years preceding the DHS survey. Multilevel logistic regressions stratified by urban and rural locale were used to model associations between women’s consumption of IFA supplements and the health facility service environment, controlling for relevant covariates.Results: More than two-thirds of facilities with ANC services in Haiti and almost all ANC facilities in Malawi had IFA supplements available. Over 60% of ANC clients in Haiti and over 80% in Malawi received IFA supplements or an IFA prescription. Counseling on IFA was less common and focused on how to use IFA; few women were counseled on side effects. Only 42% of women in Haiti and 35% of women in Malawi took IFA supplements for at least 90 days. Multivariable models indicated that in both countries, adherence to IFA supplementation in rural areas was significantly associated with a high level of availability of ANC facilities offering IFA. IFA counseling was also positively associated with the IFA supplement adherence in rural Malawi but not in Haiti. IFA supplement adherence was consistently associated with the completion of four or more ANC visits in both countries.Conclusions: Continued efforts are required to address access to IFA supplements through improving both the use of ANC services and their quality, particularly in provider counseling.

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