Compliance to Iron Supplementation guidelines during pregnancy among women attending antenatal clinics, Al Yamamah hospital, Riyadh, Saudi Arabia, 2004

Iron deficiency anemia is the most common nutritional disorder in the World.

Pregnant women are at especially high risk because of significantly increased iron requirements. Routine use of daily iron supplements is recommended after the twelfth week of pregnancy. However, the major obstacle to iron supplementation is compliance with treatment. Very little consistent information exists on the factors associated with non-compliance. We decided to conduct a study to assess compliance to iron supplementation and evaluate factors affecting noncompliance among a sample of pregnant women attending antenatal clinics at Al-Yamamah hospital, Riyadh, Saudi Arabia.

A cohort (longitudinal) study was conducted among pregnant women who had been booked for antenatal care during their first trimester of pregnancy (before 13 weeks) when routine booking investigations were carried out. Study participants were recruited into the study at or after 36 weeks of gestation. A blood sample was taken from each participating pregnant woman for hemoglobin estimation at recruitment to be compared with that done at booking. Data was collected using a questionnaire of two parts. The first part was filled by direct interview and included socio-demographic and life style characteristics. Assessment of compliance to iron supplementation depended only on participants' questionnaire responses to their use during the second and third trimesters. The second part documented hemoglobin concentration measured at booking (before 13 weeks) in addition to results of blood examination done at recruitment (at or after 36 weeks).

Anemia was considered when hemoglobin level fell below 11g/d1. Impact of the explanatory variables on non-compliance and impact of non-compliance on Hb level was estimated as relative risks (RR) with 95% confidence intervals. Confounding was controlled by logistic regression analysis. Paired t-test was used to compare the mean hemoglobin levels measured at booking and at recruitment into the study to measure the impact of compliance to iron supplementation.

Three hundred and eight (308) pregnant women between gestational weeks 36-42, were recruited into the study. Their ages ranged from 17 to 45 years (mean 27 SDxx); 95% were Saudis; illiterate women constituted 11.4%, and 27% had completed university education. Housewives constituted 88.3%.

Strict use of iron supplements during the second and third trimesters was reported by 153 (49.7%); 118 (38.3%) reported partial use; and 37 (12.0%) used no iron. Reported causes of non-compliance were mainly side effects (40.3%) and forgetfulness (32.5%). Strict compliance was found to decrease with advanced maternal age (>35 years) and parity (>6), and to increase with higher educational levels (intermediate school and above) and among those who reported doing some kind of physical exercise. These differences were statistically significant. There was no difference between compliant and non-compliant women in inter-pregnancy spacing, income, work, chronic or acute illnesses and early HB level.

At booking 29.6% were anemic, with mean Hb concentration of 11.6 (SD ±1.3). At recruitment into the study 33.9% were anemic, with mean Hb concentration of 11.4 (SD ±1.3). The risk of becoming anemic was significantly associated with noncompliance to iron supplementation (Crude RR 2.4, 95% CI 1.78-3.25, P<0.000; Adjusted RR 5.4, 95% CI 2.37-12.41, p<0.001). By comparing non-compliance to strict and partial compliance separately, the risk of anemia was also highly associated with non-compliance. Logistic regression showed that education was the only factor associated with lower risk of non-compliance (Adjusted RR 0.71, 95% CI 0.52-0.96, p<0.01).

The paired t-test showed that Hb level increased significantly among strictly compliant women by 0.3 gm/ dl (95% CI 0.085-0.514; p<0.001), and significantly decreased among partially compliant women by -0.36 gm/dl (95% CI -0.629 to -0.090; p<0.001), and among non-compliant women by -1.4 gm/dl (95% CI -1.966 to -0.917; p<0.001).

Iron supplementation is the most commonly used strategy to control iron deficiency in developing countries.[1] Although this is an inexpensive and effective way of increasing hemoglobin levels, anemia during pregnancy is still a major problem in developing countries.[2] Poor compliance is the major obstacle. Measuring compliance is important, since iron supplementation is only effective over relatively prolonged periods and pill taking may be discontinued long before the regimen has had a positive impact.[3]

Research on compliance has given conflicting and inconsistent results. No uniform characteristics of a noncompliant person have been identified.[4] In the present study, illiteracy had a significant association with noncompliance (p<0.01). By comparing strict compliance and noncompliance, strict compliance de creased with advanced maternal age (>=35) and parity (>6). The percentage of strict compliance was higher among educated women and those who were doing some form of physical exercise. In multivariate analysis only education was found to have a significant effect. These findings are comparable to those reported by Gofin, who found that noncompliance was higher with increasing maternal age and parity. Good compliance was higher among educated women.[5]

In this study the main stated causes of non-compliance were side effects 40.3% and forgetfulness 32.5%. In a study investigating the determinants of compliance with iron supplementation in South East Asian countries, only 3% of Burmese women stated side effects as the reason for stopping iron supplements, while 30% of Thai women complained of side effects.[3]

The importance of compliance to iron supplementation during pregnancy should be enforced to pregnant women by health education to improve their awareness, and explaining the possible side effects of iron deficiency anemia during pregnancy. Pregnant women should be provided with educational and reminder aids that may improve compliance. Intermittent dosing has shown to be a realistic alternative to daily supplementation and produces fewer side effects. Improving the quality of the patient-provider relationship is pivotal in improving compliance to iron supplements and other medical treatments.