Maternal Knowledge Associated with the Prevalence of Iron and Folic Acid Supplementation Among Pregnant Women in Muntinlupa, Philippines: A Cross-Sectional Study

Introduction

The World Health Organization (WHO) estimates that worldwide, 613 million women at reproductive age are anemic, and a vast majority of anemic pregnant women reside in Asia and Africa.¹ In the Philippines, anemia prevalence among pregnant women remains high as shown in the National Nutrition Surveys in 2003 (43.9%), 2008 (42.5%), and 2013 (25.2%).^2,3 Anemia during pregnancy (ie hemoglobin level less than 11 g/dL) can lead to adverse maternal and perinatal outcomes, including mortality.^4–13 The WHO recommends that all pregnant women in areas where anemia is prevalent should receive iron and folic acid supplementation (IFAS).^1,14 Despite the WHO recommendations, the utilization of IFAS is still low in many countries, especially those with low economic resources.^11,15

The Philippines’ national guideline for the prevention of micronutrient deficiencies highlights the need for daily IFAS during pregnancy.¹⁶ Various factors such as socio-demographic and health factors determine the IFAS regime for pregnant women in some areas including the Philippines. These factors include forgetfulness, travel, age, literacy, socioeconomic status, cost of iron and folic acid tablets, perceived side effects, supplement stock-outs, birth order, difficult accessing and poor utilization of antenatal health care services, and comprehensive knowledge of anemia as well as quality of counselling on IFAS during pregnancy.^17–34 Nevertheless, supplementation is the most widely employed strategy to alleviate iron deficiency, both globally and locally.^3,35 Women take IFAS during pregnancy to prevent specific micronutrient deficiencies under the programs provided by the government of the Philippines.^3,35,36 In the Philippines, Patient-level care is provided at widely utilized barangay (village) health stations (BHS) that are operated by trained midwives. The midwife in each BHS identified all the pregnant women who had received IFAS from that BHS during their pregnancy.³⁷ At each monthly prenatal visit to the BHS, IFAS is provided free of charge to pregnant women.^35,38 The Philippines National Survey in 2008, which measured the uptake of IFAS, found consumption of 82.4% of prescribed pills among pregnant women.^39,40 Thus, taking iron and folic acid supplements is an important strategy to prevent anemia among pregnant women. The present research is one of the studies that seek to check the effectiveness of the current Philippines program with the strategy whereby women would receive free IFAS from the BHS during pregnancy.

However, no published data exist to assess the administration of such supplementation and its associated factors among pregnant women in the Philippines. The Muntinlupa City of the Philippines is located in the Luzon region and divided into nine districts, and the city has a public city hospital—the Muntinlupa City hospital. The hospital provides health services at the lowest possible costs; therefore, in Muntinlupa, not only rich but also poor pregnant women use public hospitals. Although it is often difficult to approach poor pregnant women in studies, this study was able to approach pregnant women across all economic levels by conducting the study at the hospital. Thus, this study was conducted specifically to assess the prevalence of IFAS among pregnant women and its associated factors in Muntinlupa, Philippines.

Patients and Methods

Study Site and Design

A cross-sectional study was conducted at the women’s health center in the hospital of Muntinlupa City and data were collected between March and August 2019. In addition, 900 pregnant women were receiving antenatal care during the data collection period based on a search of electronic records. Muntinlupa City has nine districts, each with one or two government health centers, including an outpatient clinic. The Muntinlupa City hospital provides health services at the lowest possible costs. In addition, the women’s health center in the hospital provides counseling to all women living in the area.

Sample Size Determination and Sampling Procedure

The required sample size for this study was determined using the single population proportion estimation formula and considering the following assumptions: the rate of taking IFAS among pregnant women was 82.4% in 2008 in the Phillippines,³⁹ a 95% confidence interval, and 5% acceptable margin of error. The calculated sample size required 267 participants. Finally, considering a 10% non-response rate, the final sample size was set at 280. After the proportional allocation of pregnant women in the women’s health center, a systematic random sampling technique was employed to include 280 participants. Sampling fraction (K) was N/n = 900/280 = 3.2. Thereafter, the lottery method was employed to identify the first pregnant woman for an interview and upon selection, every third pregnant woman thereafter was chosen to commence the interview. Consequently, all women were identified.

Study Population and Sampling

The study population consists of pregnant women, aged 18–45 years, attending antenatal check-ups in the respective hospital and living in Muntinlupa City. Each participant provided written, informed consent. Women who were seriously ill at the time of data collection were excluded. The interview was conducted just after receiving the antenatal care service.

Data Collection Methods

Data were collected using the interviewer-administered questionnaire. A structured, interviewer-administered questionnaire consisting of 26 closed-ended questions were developed, pretested, and used in this study. Questions were categorized into: socio-demographic characteristics (6), maternal knowledge on taking IFAS and knowledge on major signs and symptoms of anemia (19), and current practices towards IFAS (1). To ensure the reliability of the questionnaire, we adopted a test-retest method where a repeat pre-test was conducted after two weeks, while Cohen’s kappa statistic was used to measure the level of agreement between the results from the pre-tests. Since all the questions had a kappa value of above 0.7 after the comparison, the questionnaire was considered reliable, thus, all the questions were retained. To ensure validity, the tool was shared and discussed with experts from the division of nutrition of the City Government Office, as well as the study supervisors. The obtained feedback was used to refine the tool. The questionnaires, which were written in Tagalog (ie the national language of the Philippines), were administered by trained research assistants to all pregnant women who met the inclusion criteria and consented to the study.

Data Analyses

Descriptive statistics were employed to describe the study population in relation to socio-demographic and other relevant variables and to display findings through means, percentages, and 95% confidence intervals. The primary outcome variable for this study was the prevalence of IFAS, which was assessed with the question: “Have you taken IFAS during the current pregnancy?” To assess the level of knowledge about IFAS during pregnancy, respondents were asked three questions including (1) major signs and symptoms of anemia during pregnancy, (2) the benefits of taking IFAS, and (3) side-effects of taking IFAS. The respondents’ level of knowledge was computed by summing up seven items with respect to the signs and symptoms of anemia (“Feels weak,” “Looks pale,” “Palpitations,” “Headaches,” “Dizziness,” “Tiredness and easily fatigued,” and “Swollen legs”), five items concerning the benefits of IFAS (“Prevents anemia among pregnant women,” “Protects mother from sicknesses,” “Gives mother strength during delivery,” “Increases the amount of blood,” and “Facilitates the fetus to grow healthy and strong”), and seven items regarding the side-effects of IFAS (“Epigastric pain,” “Abdominal pain,” “Nausea,” “Vomiting,” “Diarrhea,” “Constipation,” and “Feces may turn black”). A correct answer for each item was scored as “1” and the incorrect answer was scored as “0.” Pregnant women were classified as highly knowledgeable and slightly knowledgeable about the benefits and side effects of taking IFAS and major signs and symptoms of anemia during pregnancy. Those who scored greater than or equal to the mean value were considered as highly knowledgeable and those who scored less than the mean value were considered as slightly knowledgeable. The distribution of the knowledge scores was approximately normal; therefore, the average value was used for the analysis. To test for multicollinearity among independent variables, we ran collinearity diagnostics to calculate the variance inflation factor and tolerance for each variable. Bivariate logistic regression analyses were carried out to evaluate the unadjusted associations between dependent variables and each of the independent variables. Significant variables in the bivariate logistic regression analyses (p-value < 0.01) were incorporated into the multivariable logistic regression analyses to identify factors associated with the prevalence of IFAS among pregnant women.

In this study, pregnant women who did not answer questions about their age, gestation, and whether they took IFAS were excluded from the analysis. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) 26.0 (IBM Corp., Armonk, NY, USA).

Ethical Considerations

The study was conducted by following per under the declaration of Helsinki. The study was approved by the Hospital of Muntinlupa, Research Operation Office (No. 2019–02), and Kobe City College of Nursing, Ethics, and Research Committee (No. 18112–05). Participation in the study was purely voluntary. The study participants provided verbal and written informed consent before the commencement of the interview. Participants were told they could withdraw from the study anytime without any consequences. The purpose of the study and the assurance of confidentiality of information were explained to participants. They were also told they could decide not to answer any question they felt uncomfortable with.

Results

A total of 280 pregnant women participated in the study. The mean age of the study participants was 28.3 (SD ± 6.5) years, with a majority (51.1%, n=143) between 25 and 34 years of age. Regarding their occupational status, 35.6% (n=98) were employed. Relating to the highest level of education attained by the respondents, a majority (88.2%, n=246) had a secondary school degree or above. The highest proportion of respondents (59.6%, n=159) earned an average household monthly income below 9999 Philippines pesos. The poverty threshold of the Philippines in 2018 was 10,000 Philippines pesos.⁴¹ More than half of the women were multipara (59.3%, n=166). Furthermore, the mean gestational age of pregnant women was 29.9 (SD = ±8.7) weeks, and the majority of the participants were in their third trimester (78.2%, n=219) (Table 1).

Table 1 Socio-Demographic Characteristics, Prevalence of IFAS, and Maternal Knowledge of Pregnant Women (n=280)

Among the respondents, the majority (85.6%, n=238) were taking IFAS during their current pregnancy. Those found knowledgeable in the assessment of various aspects of IFAS were categorized as follows: knowledge on signs and symptoms of anemia: 45.9% (n=128), benefits of taking IFAS: 45.3% (n=126), and side effects of IFAS: 15.4% (n=42) (Table 1). The highest proportion of knowledge related to the various benefits of IFAS among pregnant women was for “Prevents anemia among pregnant women” (76.4%), followed by “Increases the amount of blood” (50.7%), “Facilitates the fetus to grow healthy and strong” (46.1%), “Protects mother from sicknesses” (43.9%), and “Gives mothers strength during delivery” (41.1%) (Figure 1).

Figure 1 Knowledge status on benefits of iron and folic acid supplementation among pregnant women.

Pregnant women reported various sources of IFAS information. The main source of information was health care providers (41.8%). Other sources of information included community health workers (CHWs) (14.6%), relatives/friends/neighbors (8.6%), the Internet (6.8%), posters/television/radio (5.4%), newspapers/magazines/books (1.4%), and community leaders (0.4%) (Figure 2).

Figure 2 Sources of iron and folic acid supplementation information.

In the logistic regression analysis (Table 2), maternal knowledge on benefits of taking IFAS was significantly associated with iron-folic acid consumption (OR=2.50, 1.04–5.97, P=0.04).

Table 2 Multivariate Regression Analyses of IFAS Prevalence Status Among Pregnant Women

Discussion

This study sought to assess the prevalence of IFAS among pregnant women and its associated factors. The main findings of the study were: (1) The majority of the women took IFAS during pregnancy; (2) less than half of the respondents had a high level of IFAS knowledge; (3) the main source of IFAS information was health care providers; (4) maternal knowledge on benefits of taking IFAS was the main factor significantly associated with prevalence of IFAS.

Notably, the prevalence rate of IFAS in this study (85.6%) was almost the same as the rate of the Philippines National Survey (82.4%) in 2008.³⁹ Similar findings on the prevalence of IFAS have also been reported in neighboring countries, such as Cambodia⁴² and Nepal.⁴³ This study found that pregnant women who were highly knowledgeable regarding the benefits of taking IFAS were more likely to continue taking IFAS than those who were slightly knowledgeable. These findings are consistent with reports on IFAS from similar rural settings in low and medium-income countries (LMIC), such as Indonesia,⁴⁴ Ethiopia,^23,45 and other countries (ie Afghanistan, Kenya, Nigeria, and Senegal).⁴⁶ Thus, successful uptake of IFAS is linked to knowledge pertaining to the benefits of taking IFAS during pregnancy. Findings from this study show that such knowledge during pregnancy has a significant effect on the prevalence of IFAS. Knowledge about IFAS is a crucial channel for taking iron and folic acid during pregnancy. Therefore, the observed relationship between the level of knowledge concerning IFAS and the prevalence of IFAS is as expected. This finding is consistent with studies conducted in other areas of the Philippines and other countries.^{21,26,35,47–49}

From this study, it was found that less than half of the women did not know that IFAS benefits include strengthening mothers during delivery and facilitates the fetus to grow healthy and strong. Few studies discussed the detailed content of the educational messages used to describe the benefits of taking IFAS. Most research conclude that women need to be motivated to take IFAS but focus on “benefit” messages such as “stronger” mothers, “healthier” babies, and reinforcing the belief that iron “increases the production of blood.”⁵⁰ Further, this study showed that many pregnant women did not know about the side effects of taking IFAS. It has been reported that side effects and management of taking IFAS are important for improving prevalence of IFAS.²³ Education about taking IFAS through antenatal care services is effective, but education focused on strengthening the benefit message as well as the side effects and its management are also expected. Moreover, these findings necessitate counseling on specific IFAS aspects concerning pregnant women and are supported by studies conducted in Ethiopia,^51,52 Iran,⁵³ and Pakistan.⁵⁴

When aggregated by source, the majority of women in this study reported their source of information was the health care provider. This was followed by CHWs, friends/neighbors, the Internet, poster/television/radio, books, and finally community leaders. Health care providers could play a major role in advocating counseling for IFAS to increase knowledge about IFAS among pregnant women; about one-third of health care providers were CHWs. Interestingly, friends, the Internet, and television/radio was not the main source of information. Possible explanations for this finding may include that (a) CHWs are closer to the community resulting in better interpersonal communication and hence better explanations to women about IFAS;⁵⁵ (b) information that passes through friends, the Internet, and television/radio is not usually prepared by professionals who know how to effectively reach the community with messages. In the Philippines, CHWs are known as Barangay Health Workers (BHW). Our previous publication reported that the BHWs play a potentially important role in supporting women during pregnancy and postpartum through home-visit services in the community⁵⁶ Therefore, increasing refresher training on IFAS among CHWs to enhance their IFAS knowledge is important as they are a common source of IFAS information as in addition to health care providers.

It has been also reported that pregnant women’s husbands or family members contribute to the success of managing anemia in pregnancy.⁵⁷ Therefore, it is important for health care providers to educate not only pregnant women but also their husbands and family members. There is a need to constantly provide pregnant women and their family members with information, education, and communication materials on IFAS, which they can always refer to and refresh their knowledge. Additionally, it might be necessary to provide a counseling program that improves the knowledge of not only pregnant women but also their husbands and families by utilizing CHWs.

Limitations

This study has some limitations. First, a few of the women in the first trimester might not have had taken IFAS yet because they had not received their first antenatal care session for receiving IFAS in BHS. Second, the small sample size limited the logistic regression analysis. Third, the study samples were selected from a hospital-based setting, and the level of knowledge could be different from a community-based setting. Fourth, the level of knowledge regarding IFAS among pregnant women was determined using a self-report survey, which is prone to bias and might affect the estimation of the actual level of knowledge of the target population. Finally, the types of factors considered to be associated with IFAS were limited.

Conclusion

Maternal knowledge about the benefits of taking IFAS was significantly associated with the prevalence of IFAS among pregnant women. The main source of IFAS information was health care providers and CHWs. Thus, there is a pressing need to improve health education on the benefits of IFAS among pregnant women to increase its prevalence. This underscores the knowledge level needed to support women through enhancing the involvement of health care providers and CHWs.