ABSTRACT
As per the 2023 estimates, the global prevalence of anaemia among Women of Child Bearing Age (WCBA), 15-49 years was about 32.8%, with more than 30% of the cases being in Sub- Saharan Africa. Approximately 50% of the cases were considered to be due to iron deficiency. According to the World Health Organization, about 20% of perinatal mortality and 10% of maternal mortality in Sub-Saharan Africa is attributed to iron deficiency anaemia. In Nigeria, only about 8% pregnant women take Peri-conceptional folic Acid (IFA) supplements for more than 90 days, while over 30% do not take them at all. In Birnin kebbi, only 8.3% of WCBA had received Iron folate supplements at the third trimester of their pregnancy, contrary to the Ministry of Health recommended dose of 60 mg/day of iron and 400µg/day of folic acid respectively for 180 days. This is a clear indication that there is low practice of IFA supplementation among WCBA in Birnin kebbi. The study assessed factors influencing Peri-conceptional folic Acid (IFA) supplements uptake among WCBA in Rivers state. This was an analytical cross-sectional survey done between January and March 2015. The target population was 270,982 WCBA from which a sample of 400 was selected using stratified random sampling method. Data was collected using semi-structured questionnaire from 399 WCBA and analyzed using frequencies, percentages, chi-square test and regression analysis. Inferences were drawn at 95% level of confidence and results were presented using tables and figures. Results indicated that 342 (85.7%) of the WCBA had used IFA supplements in the last five years preceding the study; WCBA aged 15-26 years were 78% less likely to uptake IFA supplements compared to those aged 26-36 years; WCBA who had no formal education were 92% less likely to uptake IFA supplements compared to those with secondary level of education; WCBA who did not receive IFA supplements during pregnancy were 93% less likely to uptake IFA supplements compared to those who received; WCBA who did not take IFA drugs as per prescription were 90% less likely to uptake IFA supplements compared to those who did; while WCBA whose source of information on IFA supplements was TV and radio were 87% and 90% respectively less likely to uptake IFA supplements compared to those whose source was hospital. The study concluded that majority of WCBA in Birnin kebbi LGA had taken IFA supplements in the last five years (between January 2016 and December 2019) preceding the study; socio-demographic and socio-economic conditions of the WCBA including age and education level had significant relationship with practice of IFAs; practices such as practice of IFAs during pregnancy and taking IFAs as per prescription had significant relationship with practice of IFAs; and sources of information on IFAs had significant relationship with practice of IFAs amongst WCBA in Birnin kebbi LGA. The study recommends that the ministry of health and county department of health should promote behavior change communications among young WCBA to increase both demand and compliance to IFA supplementation; sensitize the health care workers to provide information on health benefits of IFA supplementation prior to conception and throughout pregnancy; and develop effective strategies to disseminate information on IFA supplementation to complement public health facilities.
CHAPTER ONE INTRODUCTION
1.1. Background Information
Maternal anaemia is a critical health challenge worldwide that affecting approximately 500 million women of childbearing age (WCBA), 15-49 years yearly (Young, 2018). The world prevalence of anemia among pregnant women in 2023 was estimated at 40.1%, while that of non-pregnant women was about 32.5%, and approximately 32.8% for all WCBA (World Health Organization (WHO), 2018; Development Initiatives, 2018). In high-income countries, the prevalence of anaemia among non-pregnant and pregnant women is low compared to low-and-middle-income countries (Stevens et al., 2013). In 2011 for instance, prevalence of anaemia among non-pregnant WCBA in high- income countries stood at 16% compared to African countries (North Africa 33%, central and West Africa 48%, East Africa 28% and Southern Africa 28%) (Stevens et al., 2013). According to the 2023 estimates, the prevalence of anaemia among WCBA in Nigeria was 27.2%, with the prevalence among pregnant women standing at 38.2% and non-pregnant women at 26.2% (WHO, 2018).
Anaemia has major consequences on human health as well as social and economic development. Anaemia is the world’s second leading cause of disability and is associated with maternal and child morbidity and mortality such as increased risk of miscarriage, stillbirth, prematurity, and low birth weight of the baby (WHO, 2019). It is responsible for about more than 115,000 maternal deaths and 591,000 perinatal deaths globally per year, of which three-quarters occur in Africa and South-east Asia (Stevens et al., 2013).
The WCBA are said to be anaemic when their serum hemoglobin levels are less than 110 g/L in the first and last trimesters of pregnancy, at sea level while in the second trimester of pregnancy, the level of hemoglobin typically declines by approximately 5g/L (WHO, 2011). However, anaemia is considered iron deficiency anaemia (IDA) when it occurs together with some evidence iron deficiency (e.g. low ferritin levels). Iron deficiency and infections are the most prevalent etiological factors of anaemia among WCBA (Stevens et al., 2013). Other factors contributing to anemia include deficiencies of nutrients such as vitamin A, vitamin B12, folate and riboflavin as well as thalassemias and hemoglobinopathies (WHO, 2015; Balarajan et al., 2011).
Owing to the fact that anaemia is a multi-factorial disorder, a multi-pronged strategy is needed for its prevention and mitigation among WCBA. To alleviate maternal anaemia, the WHO advocates for a daily practice of 30-60mg of iron, and 0.4 mg of folic acid throughout the gestation period (WHO, 2023). The daily use of iron folate supplements during pregnancy minimizes considerably, the prevalence of maternal anaemia, birth defects, low birth weight, spina bifida, and child mortality (Haider et al., 2013).
The Ministry of Health has been on the front line of employing the WHO IFA supplementation recommendations among WCBA. Unfortunately, the uptake and adherence rate of peri-conceptional folic acid supplements among pregnant women in Nigeria remains poor. According to the Nigeria Demographic Health Survey of 2019, compliance to iron/folate supplements by pregnant women in Nigeria was low. Nationally only 8% of the pregnant women took Iron supplements more than 90 days of the recommended 180 days. The statistics revealed that 5% of the respondents took supplements for 60-89 days, 53% took the supplements for fewer than 60 days and 30% reported that they did not take iron supplements at all during their last pregnancy.
In spite of considerable developments in the Nigerian health care system following devolution of health resources, only a marginal reduction in the prevalence of anemia among WCBA has been recorded, and it varies from one environment to another (Kilonzo, Kamaara & Magak, 2022). This can be generally attributed to lack of awareness among many WCBA regarding the effects that their own health status and health-related behaviors may have on the fetus during pregnancy. While antenatal care is established in the maternal, newborn, and child health (MNCH) continuum, it overlooks the most fundamental phase of embryonic development, which often occurs before a woman even becomes aware of her Pregnancy (Dean et al., 2013). The evidence is increasingly pointing towards earlier care prior to pregnancy to promote women health and healthier pregnancy outcomes for the mother and newborn. From several studies, practice of folic acid supplements before conception and during the first trimester may reduce the risk of women bearing children with neural tube defects by 72 -100% (Dean et al., 2013).
This study considered a multi-dimensional approach for the prevention of maternal anaemia among WCBA. Such a strategy is not limited only to daily dosage and intermittent iron supplementation as proposed by WHO, rather it also incorporates aspects of nutrition, fortification using micronutrient powders, staple foods and condiment fortification and efforts to enhance food security and dietary diversification.
Nigeria is home to more than 40 million people, 80% of whom live in rural areas and rely almost entirely on agriculture (Transform Nutrition, 2011; CAADP, 2013). More than 10 million (almost a third of the population) are chronically food insecure (Republic of Nigeria, 2011). The country’s food and nutrition insecurity is often attributed to the poor performance of the agricultural sector. As reported in Nigeria’s National Food and Nutrition Security Policy (NFNSP) of 2011, per capita food availability in the country had declined by more than 10% in the past 30 years (Republic of Nigeria 2011).
Nigeria’s situation of food security and nutrition is further complicated by an unstable economic environment, a recent rise in food and fuel prices, adverse weather conditions, insufficient budgetary allocations, and weak sector coordination putting over 3 million under starvation annually (Transform Nutrition, 2011). Malnutrition exists in various forms, including acute and chronic undernutrition, micronutrient deficiencies, as well as overweight and obesity. These conditions affect primarily the pregnant and lactating women and children under five years of age (u5s) contributing substantially to their morbidity and mortality (MoPHS, 2012).
In view the foregoing discussion, supplementation of pregnant women with peri-conceptional folic acid coupled with fortification of staple foods are among the nutrition interventions that influence maternal and child nutrition. Commonly known as “High Impact Nutrition Interventions” (HINIs), the interventions form part of the 12 of which were adopted by UNICEF and the Ministry of Public Health and Sanitation (MoPHS), then later ratified by Nigeria’s Nutrition Inter-ministerial Coordination Committee in 2016. Unfortunately, antenatal coverage in Nigeria remains low at 47% for the 4th visit, the aforementioned interventions notwithstanding (WHO, 2013). Rivers state has not been reported iron folate uptake as an intervention to maternal anaemia, Further, there was inadequate documentation at various levels of health services.
This study, therefore, evaluated the factors influencing the Peri-conceptional folic acid supplements uptake among WCBA in Birnin kebbi LGA. As a baseline survey, the findings of this study and recommendations therein will aid stakeholders and policy makers in the Ministry of Health and County governments to establish pragmatic strategies that will improve maternal outcomes by enhancing the practice of IFAs among WCBA.
1.2. Statement of the Problem
Iron deficiency anaemia remains a momentous public health challenge around the world, with Sub-Saharan Africa leading in prevalence. As at 2023, the prevalence of anaemia among WCBA was estimated 32.8% globally, with Sub-Saharan Africa accounting for more than 30% of those cases. Also, approximately half of the global cases of anaemia were attributed to iron deficiency (WHO, 2018). Many women in Sub Saharan Africa have not adhered to the WHO recommendation that women of reproductive age should take IFA supplements. Consequently, such women whose practice of folic acid is inadequate are more likely to have children with birth defects and/or may experience high rates of maternal and child morbidity and mortality (Rahman et al., 2019). As indicated by the the WHO, about 20% of perinatal mortality and 10% of maternal mortality in Sub-Saharan Africa is ascribed to iron deficiency anaemia (WHO, 2011).
In Nigeria, IFAs is routinely administered to all women attending antenatal clinics in public health facilities, at no cost. Despite free distribution, adherence to IFAS uptake has remained poor over the years with only about 8% of pregnant women taking IFAS for more than 90 days, while over 30% fail to take them altogether (KNBS, 2015). The failure to take the iron folate supplements has elevated the prevalence of anaemia among pregnant women which is estimated at 38.2% as of 2023 (WHO, 2018). According to the available clinical attendance records in Birnin kebbi, only 8.3% of WCBA had received the Iron folate supplements at the third trimester of their pregnancy, converse to the recommended dose by the Ministry of Health iron in pregnancy of 60 mg/day and folic acid 400µg/day respectively for 180 days. This is a clear indication that there is poor practice of iron folate supplementation among WCBA in Birnin kebbi despite various interventions by the Ministry of Health.
The statistics from Rivers state, specifically Birnin kebbi reveal that some women have not complied with iron folate uptake. Moreover, there are no proper records on IFA supplements at the health facilities and proportion of reproductive age women actually using the supplements. Therefore, the present study set out to investigate the factors influencing IFA supplements uptake among WCBA in Rivers state.
1.3. Objectives
1.3.1. General Objective
To determine the knowledge and practice of Iron Folic Acid supplementation (IFA) among WCBA in Rivers state, Nigeria.
1.3.2. Specific objectives
The study was guided by the following specific objectives:-
i. To determine the proportion of IFAs uptake in the last five years among WCBA in Rivers state.
ii. To assess the practices influencing IFAs uptake among WCBA in Rivers state.
iii. To determine the socio-demographic and socio-economic factors influencing IFAs uptake among WCBA in Rivers state.
iv. To determine health related factors influencing IFAs uptake among WCBA in Rivers state.
1.4. Research Questions
The study was guided by the following research questions: -
i. What is the proportion of IFAs uptake in the last five years among WCBA in Rivers state?
ii. What are the practices influencing IFAs uptake among WCBA in Rivers state?
iii. What are the socio-demographic and socio- economic factors influencing IFAs uptake among WCBA in Rivers state?
iv. What are the health related factors influencing IFAs uptake among WCBA in Rivers state?
1.5. Justification of the Study
The findings on the proportion of IFAs uptake among WCBA in Rivers state provide feedback to key stakeholders in the county and national governments on the effectiveness of interventions put in place and thus inform policy review and reforms.
The findings on the practices influencing IFAs uptake among WCBA provides insight on whether or not the WCBA are well informed on the best practices of IFA supplementation in relation to their daily life practices. Information obtained from the study will assist stakeholders in the health sector to develop behavior change communication strategies and materials aimed at influencing behavior change towards effective IFAs uptake among WCBA.
The findings on the socio-demographic and socio-economic characteristics influencing IFAs uptake among WCBA in Rivers state will provide a detailed understanding of the distribution of IFAs uptake across the various socio- demographic and socio-economic clusters and thus inform targeted policy interventions.
The findings on the health-related factors influencing IFAs uptake among WCBA provides a guide to enhance community strategy towards strengthening continuous health education on IFA supplementation at facility and community level.
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