Community and Public Health Nutrition
Objectives : Maternal anemia is a major public health problem in many low and middle income countries. In Malawi, consumption of iron folic acid supplements (IFA) has remained low and unchanged since 2004, even with the support of national policy and programs. To understand program implementation challenges, our study examined the relationship between the IFA-related health service environment (HSE) during antenatal care (ANC) and women’s adherence to IFA supplementation guidelines.
Methods : Data from the 2015-16 Malawi Demographic and Health Survey (DHS) and the 2013-14 Malawi Service Provision Assessment (SPA), both of which collect GPS data of clusters or health facilities, were used. Each DHS cluster was linked to SPA facilities within a specified buffer distance (5 km for urban and 10 km for rural) using GPS data. IFA-related HSE was defined as availability of IFA, observed prescription of IFA, and observed counseling on IFA in health facilities within the buffer. The HSE variables were aggregated to the cluster-level and classified as low, medium, or high. Multilevel logistic regressions, stratified by urban and rural locale, were used to model associations between consumption of IFA and HSE variables controlling for individual-level factors.
Results : In Malawi 44% of women in urban and 32% in rural areas reported IFA consumption for at least 90 days during their most recent pregnancy. IFA supplements were available in the majority of health facilities (94%) providing ANC. Among clients, 85% received IFA or were given a prescription, 59% were counseled on how to use IFA, and 3% were counseled on side effects. In rural areas, regression models showed that high levels of IFA availability in facilities (OR=2.07; 95% CI: 1.13-3.80) and IFA counseling (OR=1.42; 95% CI: 1.12-1.78) were associated with IFA consumption. No associations with any HSE variables were observed in urban areas.
Conclusions : Despite widespread availability and prescription of IFA supplements from health facilities, receipt of counseling was low, particularly for side effects. Findings in rural areas reinforce the importance of health system strengthening to ensure IFA availability and counseling to support IFA consumption during pregnancy. Further research is warranted to investigate factors that affect IFA consumption in urban areas.
Funding Sources : United States Agency for International Development (USAID) through the DHS Program (7200AA18C00083)