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Objectives: To determine the effect of antenatal IFA supplementation on maternal perceived birth size in Nepal using pooled data from 3 Nepal Demographic and Health Survey (DHS) 2001, 2006 and 2011. Methods: We used survival information from 13,111 most recent live-born infants. Primary outcome was maternal perceived birth size and the main exposure variable was the antenatal IFA supplementation. Birth weight was reported in 19% of live births. Perceived birth size was considered as surrogate for birth weight. Data was analysed by using STATA 13 and adjusted for the cluster sampling design. Analyses used multivariate logistic regression adjusted for 18 potential confounders. Results: Maternal use of IFA supplementation during pregnancy significantly reduced the risk of less than average birth size by 15% (aOR: 0.85 p=0.01) compared to no IFA use after adjustment for other confounders. The protective effect of IFA supplementation on less than average birth size remained there whether other antenatal services used or not (aOR: 0.81, p=0.001) compared to no IFA supplementation and no antenatal services. A slightly greater magnitude of protective effect was observed when mother used ≥90 supplements in their pregnancy (aOR: 0.84, p=0.03) than those mothers who never used any IFA supplements after adjustment for other confounding factors. Conclusions: Maternal use of IFA supplements during pregnancy significantly reduces the risk of less than average birth size in Nepal. The magnitude of protective effect on the risk of having less than average birth size was greater in infants whose mothers used ≥90 supplements in their pregnancy.
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Objectives: To examine the effect of iron-folic acid (IFA) supplementation on perceived birth size and birth weight using Pakistan Demographic and Health Survey (PDHS) 2006-07. Methods: Information from 5,692 most recent live-born infants within 5 years prior to survey was used. The primary outcomes were maternal perception of birth size and birth weight and the main exposure was any use of antenatal IFA supplements. Birth weight was reported for only 10% of live births in PDHS 2006-07. Data was analysed by using STATA 13 and adjusted for the cluster sampling design. Analyses used multivariate logistic regression adjusted for 14 potential confounders. Results: The risk of having less than average birth size babies was significantly reduced by 18% (aOR: 0.82, 95% CI 0.71, 0.96) for mothers who used any IFA supplements compared to no IFA use. A similar (18%), but non-significant reduction in the risk of low birth weight babies was found with maternal use of IFA supplements. Mothers who started IFA in the first trimester of pregnancy, significantly reduced the risk of having less than average birth size babies by 19%. Population attributable risk estimates showed 11% of ‘less than average birth size’ were attributed to non-use of antenatal IFA supplementation and universal coverage of IFA supplementation could prevent 112,000 newborns to have ‘less than average birth size’ each year in Pakistan. Conclusions: Antenatal IFA supplementation significantly reduces the risk of less than average birth size and low birth weight babies in Pakistan. Universal coverage of supplementation improves birth size.
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Objectives: To investigate the impact of a decade-long program to improve coverage of antenatal IFA supplementation on child survival in Nepal over a 15 year period from 1996 to 2011. Methods: We used pooled data of 3 Nepal Demographic and Health Survey (DHS) 2001, 2006 and 2011 with survival information from 13,106 most recent live-born infants. Primary outcomes were mortality indicators in children <5 years and the main exposure variable was the implementation of an improved IFA supplementation program. The improved program was implemented in 70 out of 75 districts in a phased manner at district level starting in 2003-04 and continuing till 2011. Data was analysed by using STATA 13 and adjusted for the cluster sampling design. Analyses used multivariate Cox proportional hazards regression adjusted for 22 potential confounders. Results: After the phased implementation of the program to improve coverage of IFA supplementation, the risk of mortality on day 0 (first day of life) and early neonatal mortality (0-7 days) significantly reduced by 56% and 55% respectively compared to before the implementation of program after the adjustment of other confounders. The protective effect of implementation of improved IFA supplementation program was also observed in infant (aHR: 0.53, p=0.011) and under five mortality (aHR: 0.64, p=0.046) compared to before the program started. Conclusions: An enhanced IFA supplementation program significantly reduces the deaths on first day of life and in early neonatal period in Nepal. The protective effect of the program was also seen in infants and in children <5 years of age.
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Objectives: To examine the effect of antenatal iron-folic acid (IFA) supplements on the risk of childhood mortality in Nepal using pooled data from 3 Nepal Demographic and Health Survey (DHS) 2001, 2006 and 2011. Methods: Survival information was used from 13,009 singleton most recent live-born infants. Primary outcomes were mortality indicators in children <5 years and the main exposure variable was any use of IFA supplements. Data was analysed by using STATA 13 and adjusted for the cluster sampling design. Analyses used multivariate Cox proportional hazards regression adjusted for 24 potential confounders based on Mosley and Chen framework for childhood survival in developing countries. Results: Any use of IFA supplements significantly reduced risk of early neonatal deaths by 45% (aHR: 0.55, 95% CI: 0.38, 0.79), and total neonatal deaths by 42% (aHR: 0.58, 95% CI: 0.39, 0.85). Similarly, the risk of infant and under-5 mortality was significantly reduced by 32% and 48%, respectively. For mothers who started ≤4 months of pregnancy and used ≥150 supplements under- 5 mortality was significantly reduced by 57% (aHR: 0.43, 95% CI: 0.23, 0.78). Population attributable risk estimates found 15% of under-5 deaths were attributed to non-use of IFA, and 29,000 under-5 deaths could be prevented in the next 5 years with universal IFA coverage. Conclusions: Antenatal IFA supplementation significantly reduces the risk of neonatal and under- 5 deaths in Nepal. The greatest impact on child survival was found in women who started early in pregnancy and took ≥150 supplements. Universal IFA coverage could improve childhood survival.
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Objectives: To understand women and healthcare providers’ perceptions, and to investigate the cultural and behavioural factors influencing the use of antenatal IFA supplements in rural and urban settings of Pakistan. Methods: Focus group discussions and in-depth interviews with mothers, currently pregnant women, community health workers and doctors were conducted in rural and urban areas of two districts of Pakistan. Data was collected between August and November 2012. Results: The majority of women were aware of the perceived benefits of antenatal IFA supplements. The facilitating factors for the women’s use of supplements were: they had knowledge of benefits; they had trust in the healthcare providers; the supplements were available; they had the financial capacity to buy them; they felt better after taking these supplements; and they received support from family members. The barriers to the women’s use of supplements were: they forgot to take them; the non-availability of supplements; their limited financial capacity to buy them; the lack of antenatal care services; family members not allowing use of the supplements; not knowing about the benefits or no education; fear or experience of side effects; considering them as contraceptives; and felt better thus stopped. Conclusions: The coverage of antenatal IFA supplementation can be improved by reducing the barriers related to the use of antenatal IFA supplementation in Pakistan. Interventions focused on providing adequate awareness, good quality counselling, reminder messages, availability of free supplements throughout pregnancy and reducing the side effects should be developed and implemented.
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Objectives: To determine the prevalence of use of antenatal iron-folic acid (IFA) supplements, and to identify socio-demographic risk factors for non-use of antenatal IFA supplements. Methods: A cross sectional household cluster sample survey was conducted in 14 districts in Pakistan. Trained female fieldworkers conducted interviews with married women of reproductive age from December 2011 to March 2012. Women with live births in the preceding five years of the survey were selected for this study. Data was analysed by using STATA 13 and adjusted for the cluster sampling design. Multivariate logistic regression models were constructed to identify the independent factors for non-use of antenatal IFA supplements. Results: Out of 6,266, 2,400 (38.3%, 95% CI: 36.6%, 40.1%) women took antenatal IFA supplements during their last pregnancy. Common sources of supplements were doctors (49.4%) and community health workers (40.3%). The mean (±SD) month of pregnancy at initiation of supplementation was 5.3 (±1.7) months. Living in Dera Ghazi Khan district (Adj OR=1.72), maternal age ≥45 years (Adj OR=2.01), no maternal education (Adj OR=2.33), no paternal education (Adj OR=1.58), belonging to the lowest household wealth index quartile (Adj OR=1.47), and no antenatal care services used (Adj OR=13.44) were risk factors for non-use of antenatal IFA supplements. Conclusions: The coverage of antenatal IFA supplements is low in the surveyed districts of Pakistan, and the lack of parental education, older aged women, belonging to poorest households, residence in Dera Ghazi Khan district and no antenatal care services used were risk factors for non-use of IFA supplements.