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Laney Graduate School

Rollins School of Public Health

Candler School of Theology

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

Wendt, Amanda Suzanne (2014)
Dissertation (222 pages)
Committee Chair / Thesis Adviser: Martorell, Reynaldo
Committee Members: Ramakrishnan, Usha ; Girard, Amy Webb ; Stephenson, Robert ; Hogue, Carol J
Research Fields: Health Sciences, Nutrition
Keywords: iron and folic acid; antenatal care; pregnancy; anemia
Program: Laney Graduate School, Biological and Biomedical Sciences (Nutrition and Health Sciences)
Permanent url: http://pid.emory.edu/ark:/25593/gjg15

Abstract

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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