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Background: Maternal anemia is a major public health problem in many low- and middle-income countries. To prevent anemia and improve neonatal health, daily consumption of iron and folic acid (IFA) supplements during pregnancy is recommended as part of routine antenatal care (ANC) services. In Malawi and Haiti, however, consumption of IFA supplements during pregnancy remains suboptimal. To inform policy and program implementation, this study examined the IFA-related services provided in health facilities and their association with women’s adherence to IFA supplementation during pregnancy.
Methods: The study used data from the Demographic and Health Surveys (DHS) and Service Provision Assessment (SPA) surveys in Haiti and Malawi—the 2016-17 Haiti DHS and 2015-16 Malawi DHS, and the 2013 Haiti SPA and 2013-14 Malawi SPA. The DHS surveys collected GPS data for enumeration areas (clusters), while the SPA surveys collected GPS data for health facilities. For the analysis, each DHS cluster was linked to health facilities surveyed in the SPA within a specified buffer distance (5 km for urban areas and 10 km for rural areas). IFA-related services were examined for health facilities within the buffer, including the availability of IFA, prescription of IFA to clients, and client counseling on IFA. Facility-level variables were aggregated to the DHS cluster level to measure the IFA-related service environment for women who received ANC services for their most recent live birth in the 2 years preceding the survey. Multilevel logistic regressions stratified by urban and rural locale were used to model associations between women’s consumption of IFA and the health facility service environment, controlling for individual-level factors that might be associated with IFA consumption.
Results: More than two-thirds of ANC facilities in Haiti and almost all ANC facilities in Malawi had IFA available. Over 60% of ANC clients in Haiti and over 80% in Malawi were observed to receive IFA or a prescription for IFA. Counseling on IFA was less common and focused on how to use IFA. Few women in either country received counseling on the side effects of IFA. Overall, only 42% of women in Haiti and 35% of women in Malawi took IFA for at least 90 days. In both countries, the proportion was higher among urban than rural women. Multivariable models indicated that in both countries, adherence to IFA supplementation in rural areas was significantly associated with a high level of availability of ANC facilities offering IFA. In Haiti, for example, compared with women living in clusters with low-level availability of facilities offering IFA, women in clusters with medium-level availability had 1.7 times higher odds of IFA compliance, and women in clusters with high-level availability had 2.3 times higher odds of compliance. IFA counseling was also positively associated with the IFA adherence in rural Malawi, but not in Haiti. IFA adherence was consistently associated with the completion of four or more ANC visits in both countries.
Conclusions: IFA consumption for 90 days or more was low in both countries. Rural women with greater access to health facilities offering ANC with IFA supplements available had a greater likelihood of IFA compliance. Continued efforts are required to address access to IFA through increasing both the use of ANC services and their quality, particularly in provider counseling. As a complement to existing facility-based programs, community-based IFA distribution may provide an opportunity to improve quality of care and to increase IFA coverage.