Iron and folic acid supplementation during pregnancy: improving program content and strategies Open Access

Wendt, Amanda Suzanne (2014)

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Anemia is a severe public health issue in Bihar, India with 60% of pregnant women estimated to be anemic. Despite the Government of India's program for universal iron and folic acid (IFA) supplementation of pregnant women, low consumption and high maternal anemia prevalence persist. With the aim of improving IFA supplementation to pregnant women in Bihar, we examined the existing program assessing 1) determinants of IFA receipt and consumption, 2) the IFA supply chain, and 3) demand side facilitators and barriers.

We found IFA receipt and consumption to be significantly associated with antenatal care factors in addition to individual demographic variables. Adequate IFA consumption was also positively associated with presence of IFA supply. For both IFA receipt and consumption, unexplained facility level variation remained. This indicates additional contextual factors that have a significant impact on women's IFA receipt and consumption in Bihar. Understanding and incorporating these contextual factors into iron supplementation programming will be an important step in improving IFA receipt and consumption in Bihar.

Inadequate IFA supply is a major constraint to the Bihar IFA supplementation program, the extent of which varies widely across districts. Qualitative data revealed specific bottlenecks impacting IFA forecasting, procurement, handling of expired drugs, storage, lack of personnel, and few opportunities for training key players in the supply chain. Improvements at all levels in infrastructure, practices, and effective monitoring will be critical to strengthen the IFA supply chain in Bihar.

We found several key knowledge gaps regarding anemia and IFA. Low awareness of anemia as a widespread issue, low counseling on potential side effects by health workers, and health worker misconceptions regarding late pregnancy IFA consumption and dairy consumption need to be highlighted through training or community awareness strategies. High awareness of the health workers' role to distribute IFA and as a resource for health information demonstrated some program successes as well. Family members can also be important sources of encouragement or discouragement regarding IFA consumption. Including family members in IFA counseling should increase awareness of IFA benefits and potential side effects to help family members be facilitators of IFA consumption for beneficiaries.

Table of Contents

Table of Contents Acknowledgments Table of Contents List of Tables List of Figures Abbreviations Chapter 1: Introduction 1 Chapter 2: Background 6 Anemia in Pregnancy - The Indian Context 6 The National Anemia Control Program 13 Evaluating Large-Scale Iron Supplementation Programs 17 Chapter 3: Methods 23 Chapter 4: Determinants of Adequate IFA Receipt and Consumption 46 Introduction 47 Methods 49 Results 55 Discussion 60 Literature Cited 69 Chapter 5: Identifying Bottlenecks in the IFA Supply Chain in Bihar, India 95 Introduction 96 Methods 98 Results 103 Discussion 113 Literature Cited 121 Chapter 6: Facilitators and Barriers to IFA Consumption in Bihar, India 138 Introduction 139 Methods 141 Results 145 Discussion 154 Literature Cited 163 Chapter 7: Summary and Conclusion 171 Key Findings 172 Strengths and Limitations 175 Proposed Actions 176 Implications and Future Research 185 Summary 188 Chapter 8: Literature Cited 197

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