Skip to main content
Download PDF

Compliance with iron-folate supplementation among pregnant women in Southern Ethiopia: a multi-center cross-sectional study

Reproductive Health volume 22, Article number: 22 (2025) Cite this article

Abstract

Background

Iron-folate supplementation is a vital and economical approach to preventing iron deficiency anemia in pregnant women. The World Health Organization targets 70% compliance, while Ethiopia's 2030 National Nutrition Program-II aims for 50% of pregnant women receiving iron-folate for 90 days by 2023. Despite various initiatives, compliance in Ethiopia continues to be low. This study examined compliance with iron-folate supplementation and its influencing factors among pregnant women in Southern Ethiopia.

Methods

A multi-center cross-sectional study was conducted among 604 systematically selected pregnant women from April 1 to 30, 2022, using structured interviewer-administered questionnaires. Data were collected via the open data kit application and analyzed in the SPSS version 25 software. Bivariable and multivariable analyses were used to identify factors associated with compliance. An odds ratio with a 95% confidence interval was used to assess the direction and strength of the association.

Results

Iron-folate supplementation compliance was 47.7% [95% CI 43.71%, 51.68%]. Being an urban dweller [AOR: 2.8, 95% CI 1.70, 4.86], attending primary education [AOR: 2.0, 95% CI 1.13, 3.75], having secondary education or more [AOR: 5.3, 95% CI 2.83, 10.22], being multiparous [AOR: 1.9, 95% CI 1.05, 3.52], receiving home visits [AOR: 2.0, 95% CI 1.08, 3.83], receiving counseling on iron-folate [AOR: 2.5, 95% CI 1.30, 4.78], possessing good knowledge of iron-folate [AOR: 3.1, 95% CI 2.04, 4.72], and having a good understanding of anemia [AOR: 3.2, 95% CI 2.12, 4.88] were significantly associated with compliance.

Conclusion

Iron-folate supplementation compliance among pregnant women in Southern Ethiopia is progressing towards the 2030 national nutrition program target, although it remains below World Health Organization recommendations. Therefore, it is crucial to strengthen home visits and counseling to enhance knowledge of Iron-folate and anemia, as well as ensure consistent intake of iron-folate.

Peer Review reports

Background

Anemia during pregnancy is defined by the World Health Organization (WHO) as hemoglobin levels less than 11 mg/dL. The most prevalent causes of anemia during pregnancy are iron, folate, and vitamin B-12 deficits [1]. During pregnancy, there is a 2–threefold increase in iron and a 10–20 fold increase in folate requirements. Thus, pregnant women are more likely to develop an iron and folate deficit due to increased iron and folate requirements caused by physiological and hormonal changes, as well as fetal demand [2, 3]. Diet alone will not suffice to meet the increased need for these nutrients. As a result, iron and folic acid deficiencies can emerge if iron and folic acid are not supplied in the food during pregnancy [4].

Anemia is a serious condition that endangers both the mother and child, potentially leading to maternal and infant mortality. Pregnant women with iron deficiency face heightened risks of infection, miscarriage, intrauterine growth restriction, low birth weight, preterm birth, pre-eclampsia, and increased maternal and perinatal mortality. Anemia during pregnancy may also cause cardiovascular dysfunction, impair physical and mental performance, reduce immune function, diminish pre-partum blood reserves, and increase the likelihood of postpartum blood transfusion. Additionally, folate deficiency can lead to anemia in the mother and birth defects in the fetus [1, 5,6,7].

Pregnancy offers a significant challenge since micronutrient intake throughout preconception and pregnancy influences fetal development and the mother's health. Inadequate diet and dietary practices during pregnancy can result in iron and folate deficits, with poor health consequences for both the mother and the fetus or baby [8]. Iron-folate supplementation (IFS) is a highly effective and cost-efficient strategy to reduce maternal anemia by 70% and iron-deficient anemia by 57% in pregnant women [9,10,11]. The WHO recommends a daily oral intake of 30 to 60 mg of elemental iron and 400 µg (0.4 mg) of folic acid for pregnant women to achieve 70% compliance and prevent maternal anemia, puerperal sepsis, low birth weight, and preterm birth [10].

WHO defines compliance with IFS as taking 65% or more of prescribed doses, equating to at least four days of supplementation per week [10]. The major concern with IFS during pregnancy in Sub-Saharan African countries is compliance, as a population-based study found that only 28.7% of pregnant women used iron supplements for 90 days or more [12, 13]. According to the Ethiopian Mini-Demographic and Health Survey (EDHS) 2019, national compliance with IFS for pregnant women for the stated duration of ≥ 90 days was 11% [14]. In 2017, only 25% of pregnant women in Arba Minch town, the administrative center of Gamo Zone, took the supplement for at least 90 days [15]. Non-compliance to IFS results in anemia during pregnancy [7]. According to the EDHS 2016, 24% of women of reproductive age (15 − 49 years) and 29.1% of pregnant women were anemic [16].

The 2030 National Nutrition Program-II of Ethiopia targets to reduce the prevalence of anemia in women of childbearing age to 18% by 2024 and 12% by 2029; to reduce the prevalence of anemia among pregnant women to 14%; and to increase the compliance of IFS for at least 90 days during pregnancy to 40% by 2020, 50% by 2023 and 90% by 2029 [17]. Despite the efforts made in Ethiopia, IFS compliance is very low both at the national and regional levels [14].

Studies have identified factors influencing compliance with iron-folate supplementation. These include socio-demographic factors like age, education, marital and occupational status, family size, and wealth [18,19,20,21,22,23,24,25]; obstetric factors such as gravidity, parity, antenatal care visits, and anemia history [4, 9, 11, 15, 21, 22, 26,27,28,29,30,31,32,33,34,35,36]; health service factors like distance to facilities, counseling, availability of supplements, and facility type [4, 20, 23, 25, 27,28,29, 33, 34, 36, 37]; and client-related factors including knowledge of anemia and supplements, perceptions, family support, fear of side effects, and forgetfulness [4, 9, 11, 20, 21, 23, 26, 30, 31, 34, 37,38,39,40].

The current evidence on compliance with IFS and the factors that contribute to it in Ethiopia, especially in the Gamo Zone, is limited. It is important to gain a better understanding of the problem by examining previously unexplored factors such as health extension workers' home visits and other health service-related factors. Therefore, this study examined compliance with IFS and its influencing factors among pregnant women receiving antenatal services in Gamo Zone, Southern Ethiopia.

Methods

Study design, setting, and periods

A multi-center cross-sectional study was conducted among pregnant women receiving antenatal services at selected public health facilities in Gamo Zone, Southern Ethiopia, from April 1 to 30, 2022. The administrative center of Gamo Zone is Arba Minch town, located 505 km south of Addis Ababa, the capital city of Ethiopia. Gamo Zone has one general hospital, five primary hospitals, fifty-seven health centers, and three hundred three health posts offering maternal and child care services. The health department in the Zone reports 376,413 women of childbearing age in 2022. Of those, 55,897 pregnant women who receive antenatal care (ANC) across all facilities, and 54,669 pregnant women receive IFS in these health facilities [41].

Population

All pregnant women who attended ANC in public health facilities of Gamo Zone were the source population. Whereas, randomly selected pregnant women who had at least one ANC in selected public health facilities of Gamo Zone and who fulfilled eligibility criteria were the study population. All pregnant women who attended ANC in public health facilities of Gamo Zone and who took IFS for at least one month before the study period were included in the study. Pregnant women not able to respond to the interview during the data collection period due to serious illness, and those whose age was < 18 years were excluded from the study.

Sample size determination and sampling procedure

The sample size was determined using a proportion of compliance to IFS by the single population proportion formula. The assumptions to be considered during the determination of the sample size were: 52.9% proportion of compliance to IFS in West Dembia district, Northwest Ethiopia [31], 95% confidence level, and a 5% margin of error. After considering the design effect of 1.5 and a 5% non-response rate, a sample size of 604 was taken for conducting the study. A multistage sampling technique was used to select study participants. First, a total of 63 public health facilities providing maternal and child health care services in Gamo Zone were stratified into 57 health centers and 6 hospitals. Out of those stratified health facilities, 2 hospitals and 11 health centers were selected for the study using the lottery method. The number of participants to be included in the study from each selected health facility was determined using proportional allocation based on the average monthly client size attending ANC and those receiving iron and folic acid supplements IFS, as recorded in the ANC registration books. The total average client size for these facilities was 1462 pregnant women. Participants were then selected using a systematic random sampling technique. The sampling interval (K) was calculated by dividing the total average monthly client size of 1462 pregnant women by the total calculated sample size of 604 pregnant women for the study. This resulted in a sampling interval (K) of approximately 2.4, which we rounded down to 2 for practical implementation. The first participant was randomly chosen, and subsequent participants were selected based on this interval until the required sample size was achieved (Fig. 1).

Fig. 1
figure 1

Schematic presentation of sampling procedure to get study participants from each public health facilities of Gamo Zone, Southern Ethiopia, 2022

Full size image

Study variables

IFS compliance was the dependent variable. Socio-demographic and economic factors such as age, residence, marital status, women’s and husbands’ education, women’s and husbands’ occupational status, family size, and household wealth index; obstetric and gynecologic-related factors such as initiation time of ANC service, number of ANC visit, gravidity, parity, history of stillbirth and abortion, history of anemia and anemia during current pregnancy; health service-related factors such as distance to health facilities, IFS counseling, availability of IFS, types of health facility, health extension workers’ provision of health education and counseling during home-to-home visit; and client-related factors such as knowledge of anemia, knowledge of IFS, perception towards anemia and IFS, forgetfulness, fear of side effect, presence of any disease before and during pregnancy were independent variables.

Data collection instrument and procedure

A questionnaire was adapted after reviewing relevant literature to collect data on socio-demographic and economic characteristics, obstetric and gynecologic, health service-related, and client-related factors. It was prepared first in English and then translated into Amharic. Data were collected by face-to-face interview technique using a pretested semi-structured interviewer-administered questionnaire with mobile data collection platform open data kit (ODK) software by fourteen Midwives who have exposure to providing maternal and child health care services and two health officers supervised the overall data collection process. Pregnant women were screened at the registration counter, and those eligible for the study were interviewed following our sampling technique before their consultation with health providers for the current ANC visit. We ensured their voluntary participation without any hesitation regarding the services provided during their visit, regardless of their involvement in the study. The specific questionnaire that we employed for our study can be located within the supplementary file provided (S1 File).

Operational definitions

Compliance to IFS: If the pregnant mother took the supplement at least four days per week in the month preceding the study [20, 23, 40]. Compliance was assessed through self-reported information from participants, supplemented by pharmacy records documenting medication withdrawals.

IFS Knowledge: This was assessed by asking women eight questions related to IFS knowledge, including topics such as the Iron/Folate drug, the health benefits of IFS for the fetus and child, beliefs about the risks of taking IFS, and knowledge of the duration for which IFS should be taken. Participants who scored at or above the mean on these questions were classified as having “good knowledge,” while those scoring below the median were categorized as having “poor knowledge” [9, 37, 38].

Knowledge of anemia: It was measured through six questions about anemia, including awareness of the illness, its causes, consequences during pregnancy, susceptibility factors, and prevention methods. Women who scored at or above the mean on these questions were considered knowledgeable about anemia [30, 37, 38].

Perceptions toward anemia and IFS: This was evaluated using ten closed-ended items rated on a 5-point Likert scale (“1 = strongly agree,” “2 = agree,” “3 = not sure,” “4 = disagree,” and “5 = strongly disagree”). A combined score based on the mean of these ten questions was calculated and classified as “positive” if the score was below the mean value and “negative” if the score was equal to or greater than the mean value [43].

Household wealth index: Women answered 25 closed-ended questions to determine the wealth index level of their households. A correct response received a score of “1”, while an incorrect response received a score of “0” [42]. The data was then analyzed using principal component analysis (PCA) to reduce the 25 elements to a single factor known as the household wealth index level [16]. Finally, it was divided into five quintiles.

Data quality assurance

The training was given intensively for data collectors and supervisors for one day. Moreover, clarity, wording, logical sequence, and skipping patterns of the questions were checked and necessary corrections were made. A reliable tool with Cronbach’s Alpha of 0.842 also was used to determine the wealth index of families [42]. Supervision was carried out on daily bases. The questionnaires were checked for completeness and consistency, and necessary corrections were made accordingly.

Data processing and analysis

Data were collected using the ODK mobile data collection platform. The dataset was then downloaded as an Excel files from the ODK aggregate server and imported into SPSS version 25.0 for data cleaning and analysis. Descriptive statistics were computed, with means/medians and standard deviations/interquartile ranges for continuous variables, and frequencies and proportions for categorical ones. After verifying assumptions, a household wealth index was created using PCA and divided into five quintiles. The outcome variable “proportion of compliance to IFS” was calculated by dividing the number of pregnant women who took IFS at least four days per week in the month preceding the study by the total sample size of 604 pregnant women, and then multiplying the result by 100 percent.

Bivariable logistic regression assessed associations between independent and dependent variables, presenting crude odds ratios (COR) with 95% confidence intervals (CI). Variables with a p ≤ 0.25 in the bivariable analysis, including Residence, Woman’s Education, Woman’s Occupation, Husband’s Occupation, Gravidity, Parity, ANC Starting Time, Frequency of ANC Visits, Distance from the Health Facility, Health Extension Workers’ Visits, Counseling on IFS, Knowledge of IFS, Knowledge of Anemia, and Perception Toward Anemia and IFS, were included in a multivariable logistic regression model using the enter method. This model aimed to evaluate adjusted associations and report adjusted odds ratios (AOR) with 95% CIs. Statistical significance was set at p < 0.05. Multi-collinearity was checked, showing the highest variable inflation factor (VIF), indicating no multi-collinearity. The Hosmer–Lemeshow goodness of fit test confirmed model fitness.

Results

Socio-demographic and economic characteristics

In this study, 604 pregnant women were successfully interviewed, with a response rate of 100%. Most of the participants, 380 (62.9%), were between the ages of 25 and 34. The participants' mean (± SD) age was 26.62 (± 5.14), with ages ranging from 18 to 40 years. Out of the participants, 566 (93.7%) were married. and 492 (81.5%) were Gamo by ethnicity. Of the participants, 352 (58.3%) were protestant and 220 (36.4%) were Ethiopian Orthodox in religion. Nearly half, of the participants, 307 (50.8%), were rural dwellers. Regarding women’s and husbands’ educational status, 278 (46%) and 369 (61%) had secondary and above education levels, respectively. Concerning occupational status, 290 (48%) women and 391 (64.7) husbands were employed. Nearly half of the participants, 314 (52%), had four or more members in the family. In terms of household wealth, 145 (24%) were the poorest, while 113 (18.7%) were the richest (Table 1).

Table 1 Demographic and economic characteristics of pregnant women attending ANC in public health facilities of Gamo Zone, Southern Ethiopia, 2022 (n = 604)
Full size table

Obstetric characteristics of study participants

Most of the participants, 454 (75.2%), were multigravida mothers. Nearly one-third of participants, 205 (33.9%), were primiparous mothers and 218 (36.1%) were multiparous. Of the participants, 519 (85.9%) and 572 (94.7%) had no history of abortion and stillbirth, respectively. In terms of ANC service initiation, 321 (53.1%) participants began using ANC services at ≤ 16 weeks of gestation. Most of the study participants, 424 (70.2%), had less than four antenatal care visits (Table 2).

Table 2 Obstetric characteristics of pregnant women attending ANC in public health facilities of Gamo Zone, Southern Ethiopia, 2022 (n = 604)
Full size table

Health service-related characteristics of study participants

Regarding the distance of health facilities from participants' house, 415 (68.7%) reach health facilities for ANC services within 30 min. Out of the participants, 287 (47.5%) were visited by health extension workers (HEWs), and 265 (43.9%) had received counseling about IFS from HEWs. Nearly half of the participants, 294 (48.7%), obtain ANC services from a health center. The majority of the participants, 516 (85.4%), responded that IFS is available in nearby health facilities (Table 3).

Table 3 Health service-related characteristics of pregnant women attending ANC in public health facilities of Gamo Zone, Southern Ethiopia, 2022 (n = 604)
Full size table

Client-related factors of study participants

Of the participants, 285 (47.2%) and 371 (61.4%) had good knowledge of IFS and anemia, respectively. More than half of the participants, 342 (56.6%), had positive perceptions towards anemia and IFS. Out of the respondents, 273 (45.2%) and 376 (62.3%) were afraid of side effects and forgot to take tables, respectively. Most of the participants, 409 (67.7%), had no history of any disease before and during pregnancy. The majority of the respondents, 515 (85.3%), had no history of anemia and anemia during pregnancy. Nearly half of the participants, 293 (48.5%), had partner and family support (Table 4).

Table 4 Client-related characteristics of pregnant women attending ANC in public health facilities of Gamo Zone, Southern Ethiopia, 2022 (n = 604)
Full size table

Proportion of IFS compliance

The proportion of IFS compliance was found to be 47.7% (95% CI 43.71%, 51.68%) while 52.3% of pregnant women were non-compliant (Fig. 2).

Fig. 2
figure 2

IFS compliance status among pregnant mothers attending ANC in public health facilities of Gamo Zone, Southern Ethiopia, 2022 (n = 604)

Full size image

Factors associated with compliance to IFS

In multivariable analysis, residence, education, parity, health extension workers’ home visits, IFS counseling, knowledge of IFS, and knowledge of anemia were significantly associated with IFS compliance.

For pregnant women, residing in an urban area increased compliance to IFS approximately 2.8 times compared to those in rural settings (AOR: 2.8, 95% CI 1.70, 4.86), while those who attended primary education exhibited twice the likelihood of adherence compared to individuals with no formal education (AOR: 2.0, 95% CI 1.13, 3.75); furthermore, a significant 5.3-fold increase in adherence was observed for those who completed secondary education and above compared to their counterparts without formal education (AOR: 5.3, 95% CI 2.83, 10.22). Additionally, multiparous women demonstrated a 1.9 times higher likelihood of compliance in contrast to nulliparous women (AOR: 1.9, 95% CI 1.05, 3.52), while those who received home-to-home visits from health extension workers were twice as likely to adhere compared to those who did not receive such visits (AOR: 2.0, 95% CI 1.08, 3.83). In addition, adherence was 2.5 times greater for pregnant women who had received counseling on IFS compared to those who had not (AOR: 2.5, 95% CI 1.30, 4.78), and participants with good knowledge on the subject were nearly three times more likely to follow the supplementation guidelines compared to those with poor knowledge (AOR: 3.1, 95% CI 2.04, 4.72), while similarly, women who possessed a strong understanding of anemia demonstrated a 3.2 times higher compliance compared to their less informed peers (AOR: 3.2, 95% CI 2.12, 4.88) (Table 5).

Table 5 Bivariable and multivariable analysis of factors affecting IFS compliance among pregnant women in Gamo Zone, Southern Ethiopia, 2022 (n = 604)
Full size table

Discussion

Despite the fact that IFS is vital and affordable for preventing and managing iron deficiency anemia in pregnant women, noncompliance remains a major public health challenge, particularly in sub-Saharan Africa, with Ethiopia being a notable example [9, 31, 37, 38]. This study focuses on examining compliance with IFS and its influencing factors among pregnant women receiving antenatal services in Gamo Zone, Southern Ethiopia.

This study revealed that, the proportion of IFS compliance was 47.7%. This finding aligns with studies undertaken in various parts of Ethiopia: Aykel Town (47.6%), Debre Tabor (44.0%), North Wollo (43.1%), Debay Tilatgen (52.8%), Western Dembia (52.9%), Gondar (55.3%) and Burji [9, 29, 31, 33, 37, 38]. This finding is lower as compared to studies done in Eastern Nepal (58.3%), India (81.7%), and different parts of Ethiopia; Dangila (76.9%), Dire Dawa (71.8%), North Shewa (60.8%), Addis Ababa (71.3%) [11, 18, 35, 36, 44,45,46,47]. This finding is also lower as compared to WHO recommendations [10]. Conversely, this finding is higher than studies reported from Malawi (37%), Kenya (32.7%), Tanzania (20.3%), and different parts of Ethiopia: Afar region (22.9%), Lay Armachio district (28.7%) and Hawassa (38.3%) [4, 22,23,24, 34, 40, 48]. Variations in a study setting, socioeconomic and cultural conditions, literacy level, and geographical disparities across study participants could all explain the disparity. This finding implies the need to work intensively to achieve the national nutrition program targets and WHO recommendations on IFS compliance.

Being an urban resident was strongly associated with IFS compliance in this study. The odds of IFS compliance were nearly three-fold greater for pregnant women who live in an urban area compared to their complements. The finding is consistent with studies carried out in Malawi and Ethiopia [22, 29, 48]. The reason could be that pregnant women in urban areas have more access to health information regarding the benefits of IFS than pregnant women in rural areas, making them more compliant. It could be because pregnant women in rural areas sometimes forget to take their supplements; after all, their days are filled with tiring and laborious work.

The educational status of pregnant women was found to be significantly linked with compliance with IFS in this study. When compared to women who are not formally educated, women who attend primary school and above have a higher likelihood of complying with IFS. This finding is supported by research from Iran and Ethiopia [2, 24, 45]. This could be explained by the potential impact of education on self-care skills since more educated women are more likely to understand and address their own needs. Women's access to health information is improved through education, as is their understanding of the importance of IFS. In addition, not attending formal education may limit women's access to information regarding the benefits of supplementation by reading, interpreting, and implementing messages from healthcare experts.

This study revealed that, being multiparous was linked with IFS compliance. Multiparous women are more likely to comply with IFS than nulliparous women. The finding is consistent with findings from different regions of Ethiopia [26, 49]. The possible explanation might be that multiparous women have more exposure to IFS, and better knowledge and understanding of care during their pregnancies because of their repetitive follow-ups at the health facilities.

In this study, receiving IFS advice during pregnancy was substantially associated with better IFS compliance. The odds of IFS compliance were more than two-fold higher for women who had received IFS counseling as compared to their counterparts. This finding is supported by studies from Senegal, Uganda, and other parts of Ethiopia [11, 26,27,28, 37, 38, 50]. This might be due to getting advice on IFS might increase knowledge, attitude, and practice toward its compliance. Also, women who received IFS counseling may comprehend the benefits, potential side effects, purposes, dosage, and duration of supplementation, making them more compliant with supplementation.

In the current study, having a weekly health extension worker's home-to-home visit was associated with IFS compliance. When compared to their counterparts, pregnant women visited weekly by health extension workers were nearly twice as likely to comply with IFS. The reason might be having a home-to-home visit by health extension workers might increase access to better health education and counseling regarding perceived risk, what to eat with the supplementation, when to take the supplementation, and what to avoid during supplementation for improving absorption and benefits of IFS. Moreover, this could be attributed to health extension workers' home-to-home visits, which could provide better anemia counseling to mothers and hence enhance compliance.

In the current study, knowledge of IFS was associated with IFS compliance. The odds of compliance to IFS were nearly three-fold greater for participants who had good knowledge of IFS as compared to their complements. This finding is in line with studies from Kenya and other parts of Ethiopia [4, 9, 11, 26, 31, 38, 50]. Participants with greater knowledge of iron-folate supplements may be better aware of the advantages of taking the pill, how to take the tablet, side effects, and issues if missed. Another reason is that having a good understanding of IFS helps mothers have a better perspective on taking the supplement effectively for both the prevention and management of anemia during pregnancy. This, in turn, may increase practice toward IFS compliance.

According to this study, having a solid understanding of anemia was significantly associated with IFS compliance. When compared to their counterparts, pregnant women who had a good knowledge of anemia had nearly three times the likelihood of IFS compliance. This finding is supported by studies from Tanzania and Ethiopia [11, 31, 34, 38, 50]. A possible explanation for this is that having an extensive understanding of anemia may assist women in having a better view of the prevention and treatment of anemia through regular supplementation during pregnancy. Another reason could be receiving counseling about IFS benefits at the community level from healthcare providers through regular home visits. This highlights the crucial role that knowledge, awareness creation, and IFS-related intervention play.

This study has some limitations that should be considered when interpreting the findings. It was an interview-based study relying primarily on the recall capacity of pregnant women, introducing a risk of recall bias that may have led to erroneous responses and affected the results. Compliance was assessed based solely on self-reported information from participants, supplemented by pharmacy records documenting medication withdrawals, yet we did not conduct pill counts to verify compliance. Furthermore, although we confirmed the presence of anemia during pregnancy, we did not measure serum hemoglobin levels.

Conclusion

The compliance with IFS among pregnant women residing in the Gamo zone of Ethiopia is making progress in alignment with the targets set by the national nutrition program for the year 2030. However, despite this positive trend, the level of compliance still falls short of the recommendations provided by the World Health Organization. Being an urban resident, having a higher educational status, being multiparous, receiving home-to-home visits from health extension workers, having good knowledge of IFS, getting IFS counseling, and having good knowledge of anemia were factors associated with IFS compliance. Hence, the provision of strengthened additional counseling services about IFS benefits, and improving knowledge about supplementation and anemia are essential strategies to enhance compliance. Rigorous community-based health education and counseling regarding IFS and anemia for improving awareness and monitoring iron-folate table count through regular home-to-home visits of community health extension workers are highly demanding. Furthermore, empowering women through education and strengthening initiatives is crucial for increasing health service use among rural women. Additional research on IFS compliance using the pill count method is needed.

Data availability

The data sets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

ANC:

Antenatal care

AOR:

Adjusted odds ratio

CI:

Confidence interval

COR:

Crude odds ratio

IFS:

Iron-folate supplementation

PCA:

Principal component analysis

WHO:

World Health Organization

References

  1. Achebe MM, Gafter-Gvili A. How I treat anemia in pregnancy: iron, cobalamin, and folate. Blood. 2017;129(8):940–9.

    Article  CAS  PubMed  Google Scholar 

  2. Siabani S, Siabani S, Siabani H, Arya MM, Rezaei F, Babakhani M. Determinants of compliance with iron and folate supplementation among pregnant women in west Iran: a population-based cross-sectional study. J Fam Reprod Health. 2018;12(4):197–203.

    Google Scholar 

  3. Committee SWRT. Regional template/guideline for the management of anemia in pregnancy and postnatally’. South West RTC Management of Anemia in Pregnancy. 2014.

  4. Kamau MW, Mirie W, Kimani S. Compliance with Iron and folic acid supplementation (IFS) and associated factors among pregnant women: results from a cross-sectional study in Kiambu County, Kenya. BMC Public Health. 2018;18(1):580.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Srour MA, Aqel SS, Srour KM, Younis KR, Samarah F. Prevalence of anemia and iron deficiency among Palestinian pregnant women and its association with pregnancy outcome. Anemia. 2018. https://doiorg.publicaciones.saludcastillayleon.es/10.1155/2018/9135625.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Liyew AM, Tesema GA, Alamneh TS, Worku MG, Teshale AB, Alem AZ, et al. Prevalence and determinants of anemia among pregnant women in East Africa: a multi-level analysis of recent Demographic and Health Surveys. PLoS ONE. 2021;16(4): e0250560.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Burke RM, Leon JS, Suchdev PS. Identification, prevention, and treatment of iron deficiency during the first 1000 days. Nutrients. 2014;6(10):4093–114.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Milman N, Paszkowski T, Cetin I, Castelo-Branco C. Supplementation during pregnancy: beliefs and science. Gynecol Endocrinol. 2016;32(7):509–16.

    Article  CAS  PubMed  Google Scholar 

  9. Boti N, Bekele T, Godana W, Getahun E, Gebremeskel F, Tsegaye B, et al. Adherence to IFSand associated factors among pastoralist’s pregnant women in Burji Districts, Segen Area People’s Zone, Southern Ethiopia: community-based cross-sectional study. Int J Reprod Med. 2018;2018:2365362.

    Article  PubMed  PubMed Central  Google Scholar 

  10. WHO. Guideline: Daily iron and folic acid supplementation in pregnant women. 2012.

  11. Solomon Y, Sema A, Menberu T. Adherence and associated factors to iron and folic acid supplementation among pregnant women attending antenatal care in public hospitals of Dire Dawa, Eastern Ethiopia. Eur J Midwifery. 2021;5:35.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Ba DM, Ssentongo P, Kjerulff KH, Na M, Liu G, Gao X, et al. Adherence to iron supplementation in 22 Sub-Saharan African countries and associated factors among pregnant women: a large population-based study. Curr Dev Nutr. 2019;3(12): nzz120.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Biru YB, Lemelem GA, G/Kiristos AF, Mezen MK. Magnitude and determinants of adherence to iron supplementation among Ethiopian pregnant women: a cross-sectional study from a national survey. Prim Health Care. 2021;11(9):401.

    Google Scholar 

  14. Ethiopian Public Health Institute (EPHI) [Ethiopia] and ICF. Ethiopia Mini-Demographic and Health Survey 2019: Key Indicators. Rockville, Maryland, USA: EPHI and ICF; 2019.

  15. Alito GA, Gebre HB, GebreKidan KG, Degaga ND, Alito SA. Adherence to prophylactic ferrous sulphate and associated factors among pregnant women attending ANC service in public health facilities of Arba-Minch Town, Southern Ethiopia. IJSBAR. 2020;54(2):138–50.

    Google Scholar 

  16. Central Statistical Agency (CSA) [Ethiopia] and ICF. Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia, and Rockville, Maryland, USA: CSA and ICF. 2016.

  17. FMOH. Government of Ethiopia National Nutrition Program 2016–2020. Addis Abeba, Ethiopia; 2016.

  18. Debi S, Basu G, Mondal R, Chakrabarti S, Roy SK, Ghosh S. Compliance to iron-folic-acid supplementation and associated factors among pregnant women: a cross-sectional survey in a district of West Bengal, India. J Fam Med Prim Care. 2020;9(7):3613–8.

    Article  Google Scholar 

  19. Deori TJ, Ramaswamy G, Jaiswal A, Loganathan V, Kumar R, Mahey R, et al. Compliance with iron folic acid (IFA) tablets and associated factors among pregnant women attending ante-natal care clinic at Sub District Hospital, Ballabgarh. J Fam Med Prim Care. 2021;10(5):2006–11.

    Article  Google Scholar 

  20. Jikamo B, Samuel M. Non-adherence to iron/folate supplementation and associated factors among pregnant women who attending antenatal care visit in selected Public Health Institutions at Hosanna Town, Southern Ethiopia, 2016. J Nutr Disord Ther. 2018;08(02):2161.

    Article  Google Scholar 

  21. Seifu CNM, Whiting SJP, Hailemariam TM. Better-educated, older, or unmarried pregnant women comply less with iron-folic acid supplementation in southern Ethiopia. J Diet Suppl. 2020;17(4):442–53.

    Article  CAS  PubMed  Google Scholar 

  22. Titilayo A, Palamuleni ME, Omisakin O. Sociodemographic factors influencing adherence to antenatal iron supplementation recommendations among pregnant women in Malawi: analysis of data from the 2010 Malawi Demographic and Health Survey. Mal Med J. 2016;28(1):1–5.

    Article  CAS  Google Scholar 

  23. Gebre A, Debie A, Berhane A, Redddy DPS. Determinants of compliance to Iron-Folic Acid supplementation among pregnant women in pastoral communities of Afar region: the cases of Mille and Assaita Districts, Afar, Ethiopia, 2015. Med Res Chron. 2017;4(4):352–62.

    Google Scholar 

  24. Agegnehu G, Atenafu A, Dagne H, Dagnew B. Adherence to iron and folic acid supplement and its associated factors among antenatal care attendant mothers in Lay Armachiho Health Centers, Northwest, Ethiopia, 2017. Int J Reprod Med. 2019. https://doiorg.publicaciones.saludcastillayleon.es/10.1155/2019/5863737.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Gebreamlak B, Dadi AF, Atnafu A. High adherence to iron/folic acid supplementation during pregnancy time among antenatal and postnatal care attendant mothers in Governmental Health Centers in Akaki Kality Sub City, Addis Ababa, Ethiopia: Hierarchical Negative Binomial Poisson Regression. PLoS ONE. 2017;12(1): e0169415.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Gebremariam AD, Tiruneh SA, Abate BA, Engidaw MT, Asnakew DT. Adherence to iron with folic acid supplementation and its associated factors among pregnant women attending antenatal care follow-up at Debre Tabor General Hospital, Ethiopia, 2017. PLoS ONE. 2019;14(1): e0210086.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Nimwesiga C, Murezi M, Taremwa IM. Adherence to iron and folic acid supplementation and its associated factors among pregnant women attending antenatal care at Bwindi Community Hospital, Western Uganda. Int J Reprod Med. 2021. https://doiorg.publicaciones.saludcastillayleon.es/10.1155/2021/6632463.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Niang K, Faye A, Diégane Tine JA, Diongue FB, Ndiaye B, Ndiaye MB, et al. Determinants of iron consumption among pregnant women in Southern Senegal. Open J Obstet Gynecol. 2017;07(01):41–50.

    Article  Google Scholar 

  29. Birhanu TM, Birarra MK, Mekonnen FA. Compliance to iron and folic acid supplementation in pregnancy, Northwest Ethiopia. BMC Res Notes. 2018;11(1):345.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Getachew M, Abay M, Zelalem H, Gebremedhin T, Grum T, Bayray A. Magnitude and factors associated with adherence to Iron-folic acid supplementation among pregnant women in Eritrean refugee camps, northern Ethiopia. BMC Pregnancy Childbirth. 2018;18(1):83.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Molla T, Guadu T, Muhammad EA, Hunegnaw MT. Factors associated with adherence to iron folate supplementation among pregnant women in West Dembia district, northwest Ethiopia: a cross-sectional study. BMC Res Notes. 2019;12(1):6.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Kiwanuka TS, Ononge S, Kiondo P, Namusoke F. Adherence to iron supplements among women receiving antenatal care at Mulago National Referral Hospital, Uganda-cross-sectional study. BMC Res Notes. 2017;10(1):510.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Demis A, Geda B, Alemayehu T, Abebe H. Iron and folic acid supplementation adherence among pregnant women attending antenatal care in North Wollo Zone northern Ethiopia: institution based cross-sectional study. BMC Res Notes. 2019;12(1):107.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Lyoba WB, Mwakatoga JD, Festo C, Mrema J, Elisaria E. Adherence to iron-folic acid supplementation and associated factors among pregnant women in Kasulu communities in North-Western Tanzania. Int J Reprod Med. 2020;2020:3127245.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Urgessa B, Abdo Z. Adherence to iron/folic acid supplementation and associated factors among pregnant women attending governmental health center in Yeka Sub City, Addis Ababa, Ethiopia. BLDE Univ J Health Sci. 2020;5(2):145.

    Article  Google Scholar 

  36. Gedefa GY, Demissie HF, Amare YW, Rameto AJ. Assessment of adherence to iron-folic acid supplementation and associated factor among pregnant women in Jida District, Ethiopia. Int J Nurs Health Sci. 2019;6(3):16–24.

    Google Scholar 

  37. Demisse B, Temesgen H, Dessie B, Kassa GM. Adherence status to iron with folic acid supplementation and associated factors among pregnant women receiving antenatal care at public health facilities in Northwest Ethiopia. SAGE Open Med. 2021;9:20503121211049936.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Assefa H, Abebe SM, Sisay M. Magnitude and factors associated with adherence to Iron and folic acid supplementation among pregnant women in Aykel town, Northwest Ethiopia. BMC Pregnancy Childbirth. 2019;19(1):296.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Anggraini DD, Purnomo W, Trijanto B. Effect of pregnant women’s knowledge and therapy regimentation towards compliance in consuming iron (Fe) tablets and anemia degree in South Kediri Public Health Center year 2016. Maj Obstet Ginekol. 2016;24(2):61–3.

    Article  Google Scholar 

  40. Kassa ZY, Awraris T, Daba AK, Tenaw Z. Compliance with iron-folic acid and associated factors among pregnant women through pill count in Hawassa city, South Ethiopia: a community-based cross-sectional study. Reprod Health. 2019;16(1):14.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Gamo Zone Health Department. Annual HMIS report of Gamo Zone Health Department. 2021.

  42. Ethiopia-DHS-2016. Equity Tool: Update. 2018.

  43. Rai SS, Ratanasiri T, Thapa P, Koju R, Ratanasiri A, Arkaravichien T, et al. Effect of knowledge and perception on adherence to iron and folate supplementation during pregnancy in Kathmandu, Nepal. J Med Assoc Thai. 2014;97(Suppl 10):S67–74.

    Google Scholar 

  44. Yadav KD, Yadav UN, Wagle RR, Thakur DN, Dhakal S. Compliance of iron and folic acid supplementation and status of anemia during pregnancy in the Eastern Terai of Nepal: findings from hospital-based cross-sectional study. BMC Res Notes. 2019;12(1):127.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Nasir BB, Fentie AM, Adisu MK. Adherence to iron and folic acid supplementation and prevalence of anemia among pregnant women attending antenatal care clinic at Tikur Anbessa Specialized Hospital, Ethiopia. PLoS ONE. 2020;15(5): e0232625.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Tegodan E, Tura G, Kebede A. Adherence to iron and folic acid supplements and associated factors among pregnant mothers attending ANC at Gulele Sub-City Government Health Centers in Addis Ababa, Ethiopia. Patient Prefer Adher. 2021;15:1397–405.

    Article  Google Scholar 

  47. Asres AW, Hunegnaw WA, Ferede AG, Azene TW. Compliance level and factors associated with iron-folic acid supplementation among pregnant women in Dangila, Northern Ethiopia: a cross-sectional study. SAGE Open Med. 2022;10:20503121221118988.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Mengistu GT, Mengistu BK, Gudeta TG, Terefe AB, Habtewold FM, Senbeta MD, et al. Magnitude and factors associated with iron supplementation among pregnant women in Southern and Eastern Regions of Ethiopia: further analysis of mini demographic and health survey 2019. BMC Nutr. 2022;8(1):66.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Niguse W, Murugan R. Determinants of adherence to iron folic acid supplementation among pregnant women attending antenatal clinic in Asella Town, Ethiopia. Int J Ther Appl. 2018;35:60–7.

    Google Scholar 

  50. Arega Sadore A, Abebe Gebretsadik L, Aman Hussen M. Compliance with iron-folate supplement and associated factors among antenatal care attendant mothers in Misha district, South Ethiopia: community-based cross-sectional study. J Environ Public Health. 2015. https://doiorg.publicaciones.saludcastillayleon.es/10.1155/2015/781973.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

The authors express heartfelt gratitude to Arba Minch University, College of Medicine and Health Sciences, for their support of this study. We extend our profound appreciation to the Gamo Zone health department, district health offices, and town public health facilities for their cooperation during data collection. Additionally, we thank the study participants, data collectors, and supervisors for their invaluable contributions.

Funding

No funding was obtained for this study.

Author information

Authors and Affiliations

  1. Student Clinic, Arba Minch University, PO Box 21, Arba Minch, Ethiopia

    Mirkat Taye

  2. South Ethiopia Region Public Health Institute, PO Box 022, Jinka, Ethiopia

    Temesgen Mohammed & Wondimagegn Taye

  3. School of Public Health, Arba Minch University, PO Box 21, Arba Minch, Ethiopia

    Mustefa Glagn & Manaye Yihune

  4. Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands

    Manaye Yihune

Authors
  1. Mirkat Taye
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Temesgen Mohammed
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Wondimagegn Taye
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Mustefa Glagn
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Manaye Yihune
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

MT participated in conceptualizing the study, designing the study, collecting data, creating the analysis plan, conducting the analysis, interpreting the results, and drafting the manuscript. TM and WT provided guidance and contributed to the design and proposal development, assisted during analysis, and edited the manuscript. MG offered guidance, participated in conceptualization and data curation, designed the analysis plan, and reviewed the draft manuscript. MY also provided guidance, participated in conceptualization and data curation, designed the analysis plan, assisted in the analysis, contributed to interpreting the results, and reviewed and edited the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Manaye Yihune.

Ethics declarations

Ethics approval and consent to participate

Ethical clearance was obtained from the Institutional Review Board (IRB) of Arba Minch University, College of Medicine and Health Sciences with a reference number of IRB/1236/2022. The study was conducted in accordance with the Declaration of Helsinki on health research. Formal official permission and support letters were obtained from the Gamo Zone health department and selected district health offices. After explaining the objective of the study, permission was also secured from selected health facilities. Written informed consent was obtained from the study participant after providing them with the information concerning the purpose of the study, benefits and harms of participating in the study. The study participants were also told that participation in the study was completely voluntary and the information will be kept strictly confidential.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Taye, M., Mohammed, T., Taye, W. et al. Compliance with iron-folate supplementation among pregnant women in Southern Ethiopia: a multi-center cross-sectional study. Reprod Health 22, 22 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12978-025-01944-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12978-025-01944-z

Keywords

Reproductive Health

ISSN: 1742-4755