Women's perceptions of iron deficiency and anemia prevention and control in eight developing countries

Abstract

The World Health Organization estimates that 58% of pregnant women in developing countries are anemic. In spite of the fact that most ministries of health in developing countries have policies to provide pregnant women with iron in a supplement form, maternal anemia prevalence has not declined significantly where large-scale programs have been evaluated. During the period 1991–98, the MotherCare Project and its partners conducted qualitative research to determine the major barriers and facilitators of iron supplementation programs for pregnant women in eight developing countries. Research results were used to develop pilot program strategies and interventions to reduce maternal anemia.

Across-region results were examined and some differences were found but the similarity in the way women view anemia and react to taking iron tablets was more striking than differences encountered by region, country or ethnic group. While women frequently recognize symptoms of anemia, they do not know the clinical term for anemia. Half of women in all countries consider these symptoms to be a priority health concern that requires action and half do not. Those women who visit prenatal health services are often familiar with iron supplements, but commonly do not know why they are prescribed. Contrary to the belief that women stop taking iron tablets mainly due to negative side effects, only about one-third of women reported that they experienced negative side effects in these studies. During iron supplementation trials in five of the countries, only about one-tenth of the women stopped taking the tablets due to side effects. The major barrier to effective supplementation programs is inadequate supply. Additional barriers include inadequate counseling and distribution of iron tablets, difficult access and poor utilization of prenatal health care services, beliefs against consuming medications during pregnancy, and in most countries, fears that taking too much iron may cause too much blood or a big baby, making delivery more difficult. Facilitators include women's recognition of improved physical well being with the alleviation of symptoms of anemia, particularly fatigue, a better appetite, increased appreciation of benefits for the fetus, and subsequent increased demand for prevention and treatment of iron deficiency and anemia.

Introduction

Iron deficiency anemia affects over two billion people worldwide. The World Health Organization estimates that 58% of pregnant women in developing countries are anemic (ACC/SCN, 1997). For women, the consequences of anemia include reduced energy and capacity for work (Basta, Soekirman, Karyadi, & Scrimshaw, 1979; Levin, 1986), poor pregnancy and birth outcomes including premature delivery, low birth weight, and increased perinatal mortality (Murphy, O’Riordan, Newcombe, Cole, & Pearson, 1986; Scholl and Hediger, 1994), and increased risk of death during delivery and postpartum (Llewellyn-Jones, 1965; Ojo & Savage, 1974; Zucker et al., 1994; Sarin, 1995). It is estimated that as many as 20% of maternal deaths are caused by anemia and that anemia may be an associated cause in as many as 50% of maternal deaths worldwide (Gillespie, Kevany, & Mason, 1991).

Most Ministries of Health in developing countries have policies to give pregnant women either iron by itself or combined with folate in tablet form or in prenatal vitamins.¹ For example, national protocols in India require the provision of 100 tablets containing 100 mg elemental iron and 0.5 mg folic acid for daily consumption to all women during pregnancy and lactation. The Government of Indonesia provides 50–60% of the recommended number of iron supplements (60 mg elemental iron each with folate) for women (90 tablets during pregnancy and 40 tablets during the postpartum period). Despite these policies, anemia prevalence has not declined significantly (Gillespie et al., 1991). Many nutrition experts believe that one of the main reasons national iron supplementation programs have failed is women's “non-compliance/non-adherence”² with taking iron supplements daily because of gastrointestinal upset and other side effects that sometimes occur when taking iron (DeMaeyer, 1989). Recent reviews on the topic suggest, however, that there are a number of reasons for ineffective programs including sporadic or inadequate supplies, poor quality tablets, problems with delivery and distribution systems, poorly trained and uncommitted health providers, ineffective communication materials to promote behavior change, lack of access to or use of prenatal care, and poor monitoring of the problem. (Gillespie et al., 1991; Galloway & McGuire, 1994; Yip, 1996).

To investigate factors that influence women's decisions to take iron supplements and suggest ways to improve existing programs, The MotherCare Project³ supported formative research, using qualitative methods, on this subject in eight countries (Bolivia, Burkina Faso, Guatemala, Honduras, India, Indonesia, Malawi and Pakistan). In all cases, except Burkina Faso, the research was subsequently used to improve the iron supplementation component of prenatal care in on-going MotherCare programs.