Quality in Primary Care (2017) 25 (3): 157-163 2017 Insight Medical Publishing Group Research Article DeterminantsResearch Article of Adherence to Iron and FolateOpen Access Supplementation among Pregnant Women in West Iran: A Population Based Cross-Sectional Study Sina Siabani Kermanshah University of Medical Sciences, Kermanshah, Faculty of Veterinary medicine, Razi University, Iran Marjan Moeini Arya Kermanshah University of Medical Sciences, Kermanshah, Iran Maryam Babakhani School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran Fateme Rezaei Kermanshah University of Medical Sciences, Kermanshah, Iran Soraya Siabani School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran, University Technology Sydney, NSW, Australia ABSTRACT Background: Iron and/or folate deficiency are prevalent Findings: Participant's ages and their gestational ages health problems in pregnant women worldwide, especially in were (27.86 ± 5.54 years) (µ ± SD) and (23.29 ± 9.86 weeks), less developed countries. Although such a problem could be respectively. Adherence and on time, respectively, were prevented by an adequate prenatal care including providing 71.6%/28% for Iron, and 81.5%/40% for Folate. Most common iron and folate supplementation, adherence to the prescribed cause of non-adherence was forgetfulness and medical side- supplementations is still problematic in many nations. effects concerning. Educational status, age and history of anemia were significantly associated with adherence to Folate, Purpose: This study was aimed to assess adherence to Iron against, Iron with a positive association with educational status and Folate supplementation, and the associated factors, among only. pregnant women in western, Iran. Conclusion: Although adherence to iron and Folate Design/methodology/approach: This cross-sectional was relatively high, most women had not started taking the study conducted on 433 pregnant women selected randomly supplements at the correct time, mostly due to insensibleness among those (n=8500) attending 40 Health Care Centers in and fear of side effects which could be improved by educating west Iran (2015-2016). A validated questionnaire was used to women and providing a strategy remembering women to take gather data related to the aim of study including demographic their pills on time. characteristics, compliance to iron/folate and reasons for non-adherence. Using Chi-square, the relationships between Keywords: Compliance; Folic acid; Iron; Pregnancy; outcome variable and predicting variables were assessed. Prenatal care Introduction [5]. Overall, the causes for pregnancy anemia are nutritional deficiencies, incompatibility between needs and nutritional Pregnancy is a critical stage of women's life affecting in intakes, parasitic and bacterial diseases and hematological the next generation. During pregnancy, iron and folic acid disorders (e.g. thalassemia). It is estimated that 20% to 80% of requirements are enhanced due to physiological and hormonal female population in the world are suffering from anemia during changes in mother and high fetal demands hence, the probability pregnancy, the majority being due to iron deficiency [6] resulted of occurrence iron deficiency and acid folic deficiency is in a hypochromic and microcytic anemia. Anemia in pregnancy relatively high [1-3]. Iron deficiency anemia in pregnancy is a is aggravated by condition such as postpartum hemorrhage and significant health problem [1-4]. active hemorrhagic events associated with delivery. In addition According to the Centers for Disease Control and Prevention's to the general adverse effects of iron deficiency anemia, it approach, hemoglobin (Hb) levels less than 11 g/dl, during the increases the risk of maternal mortality [7], premature delivery, first and third trimesters and also Hb levels less than 10.5 g/dl intrauterine growth retardation and low birth weight (less in the second trimester is considered as anemia in pregnancy than 2500 g) [8,9]. The definitive diagnosis comes from a low 158 Soraya Siabani serum ferritin level or percent transferrin saturation (TSAT) may improve outcomes [13]. In Iran, where Iron and Acid Folic plus iron bound capacity [10]. Oral iron therapy is generally are provided by Primary health care centers for all pregnant effective and convenient to prevent and treat iron deficiency women freely, adherence to Iron/Folate supplements is not anemia [11]. In pregnant women suffering from gastric bypass, optimal. On the other hand, recently, a huge governmental uterine bleeding, inflammatory bowel disease and hereditary concerning about aging population and reducing fertility rate hemorrhagic telangiectasia or in those who oral iron is to be leading to encourage people to birth more child, may increases ineffective, the intravenous iron is prescribed [10]. pregnant women resulting in pregnancy-related issues. Iron/ Folate supplementation therapy and the associating factors Pregnancy-related Folate deficiency is often associated to non-adherence or poor adherence, therefore, must be with megaloblastic anemia, low birth weight (less than 2500 clarified to be addressed appropriately. This study was aimed g) and congenital anomalies (e.g. Neural tube defects) [12]. to assess factors associated with adherence to Iron and Folate NTDs are accounted as the second common group of congenital supplementation among pregnant women in Kermanshah, Iran anomalies [13]. NTDs arise because of the defect in neurulation 2015-2016. during embryogenesis, a process that occurs in 21-28 days after conception, often before women even know they are pregnant Materials and Methods [14-16]. The burden associated with NTDs is substantial, it is usually related with other congenital abnormalities and all these Setting lead to various disabilities and financial burden on the family Kermanshah, in western Iran, with 1952433 inhabitants of and society [15]. The evidence is strong that the administration whom 964419 are women, is a capital city in which many people of acid folic 3 months before and during conception can reduce are disadvantaged. In this city, more than 40 Primary Health the risk of NTDs by 75% [12,14,15,17]. Spinabifida and Care Centers (PHCC) provide people, especially children and anencephaly is the most common neural tube defects. A bout 0.3- women, with primary care services for free. One of care taker 0.4 million infants are affected by Spina bifida and anencephaly groups are pregnant women, therefore, a good setting for our yearly. The serious defects like anencephaly is incompatible study. with life and majority do not survive and the others live with a huge disability [15]. Study design and sampling Pregnant women living in low and middle income countries, In this cross-sectional study, 433 people among pregnant suffering from a base-line malnutrition, need more attention women attending in the PHCC in Kermanshah were selected about starting Iron and Folate supplementation therapy in an to participate in the study. A multi-stage sampling technique appropriate stage of their pregnancy [12]. The World Health (including cluster sampling, proportional and then randomized Organization (WHO) recommends that all pregnant women sampling) was used to select the samples. First, the 10 PHCC should take a daily dosage of 30-60 mg of elemental Iron1 and (clusters) were selected among 40 PHCC randomly. Then, 400 µg (0.4 mg) Acid Folic as a part of antenatal and neonatal samples size for each PHCC was considered based on its care program in order to improve pregnancy outcome and population coverage and the number of pregnant women taking prevent adverse effects of elemental deficiency [3,16]. This care there. In the last stage, the pregnant women registered to includes women with normal hemoglobin (Hb) as well as those each PHCC were selected randomly using Excel randomization. with anemia of iron deficiency, however the time for starting regular taking supplement is different for those with anemia in According to two similar previous studies reporting an whom anemia must be treated before getting pregnant, if not adherence rate of 50% [21] and 40% [1] and using a confidence possible anyway, taking extra dosage of supplements during level of 95% and marginal error of 5%, the computed sample pregnancy. size was 385. On the other hand, based on Cochran table for Nowadays, providing elemental Iron/Folate supplements by determining sample size, the minimum sample size was 379. health care systems in the most of countries across the world, However considering 10-15% nonresponse, a sample size of the major problem with Iron and Acid Folic deficiency is related 433 was considered to be enrolled in this study. to non-adherence or a poor adherence arise from personal Exclusion criteria behaviors, cultural issues, environmental factors, etc. [18,19]. Most common reason declared by evidence is lack of awareness, Participants were excluded from the study if be non- Sociodemographic factors, economic status, inadequate service residential and/or were in the last month of pregnancy and/or delivery and side effects [20]. For example, women taking Iron those who did not sign consent form to participate in the study. supplements, especially those with lower price, may experience unpleasant side effects such as constipation and sometimes Instrument used for data collection diarrhea, gastric cramping, a metallic taste and thick, green and The eligible pregnant women signed consent forms were tenacious stool