Knowledge, acceptance and barriers to optimal use of iron supplements amongst pregnant women attending Mutare city clinic in Manicaland, Zimbabwe.

Abstract

Iron deficiency anaemia (IDA) is a global public health challenge, most prevalent in developing countries, including Zimbabwe. It mostly affects young children and women of childbearing age, particularly pregnant women. In the developing world, unbalanced diets which lack haemiron from animal sources due to high costs, predisposes many pregnant women to IDA. Most women usually enter pregnancy with already depleted iron stores, consequently resulting in high maternal mortality and morbidity, premature deliveries and low birth weight infants. Pregnant women with IDA have a high risk of complications at delivery and are also prone to infections. Therefore, to increase haemoglobin levels and prevent IDA, the World Health Organization (WHO) recommends a daily supplement of 60 mg of iron for all pregnant women for at least six months during pregnancy, until six weeks post-partum. This is meant to complement iron from the diet, because dietary sources of iron alone are inadequate to meet the iron requirements during pregnancy. However, there are many barriers to the acceptance and use of iron supplements among pregnant women. This is also exacerbated by poor knowledge on the importance of iron supplements during pregnancy. Mutare City, in Zimbabwe was chosen as the study site because there is a lack of published data on the use of iron supplements by pregnant women in this area. The aim of this study was to assess the knowledge and acceptance levels of iron supplements among pregnant women, attending Mutare City Clinic, Manicaland, Zimbabwe. The study also aimed to identify possible barriers to optimal use of iron supplements among the pregnant women. In addition, the study aimed to develop and test a nutrition education tool with the aim of creating awareness regarding the importance and use of iron supplements among pregnant women, thus improving acceptance and use of the supplements. The objectives of the study were as follows: (i) To assess knowledge on the importance of iron supplements during pregnancy amongst pregnant women attending Mutare City Clinic, Manicaland, Zimbabwe. (ii) To assess the acceptance levels of iron supplementation given during pregnancy amongst pregnant women attending Mutare City Clinic, as perceived by nurses and pregnant women attending Mutare City Clinic for ante-natal care (ANC). (iii) To identify the barriers to optimal iron supplementation by pregnant women attending Mutare City Clinic. (iv) To ascertain from pregnant women attending Mutare City Clinic, the form of the nutrition education tool to be developed, the importance of the tool, information and language to be used in the tool. (v) To develop a nutrition education tool for pregnant women attending Mutare City Clinic with the purpose of creating awareness of iron supplements. (vi) To test the developed nutrition education tool to determine its user-friendliness and acceptability among pregnant women attending the Mutare City Clinic. A survey was conducted to assess knowledge and acceptance on the importance and use of iron supplements by pregnant women. A total of 103 pregnant women, aged 16-36 years participated in the study and were selected on the basis of being either in their second or third trimesters of pregnancy, and attending Mutare City Clinic for ante-natal care (ANC). It was found that the pregnant women had inadequate nutrition knowledge to motivate them to consistently take iron supplements. Most pregnant women appreciated the importance of iron supplements, but lacked detailed knowledge to substantiate their need for taking them. The study therefore recommends early ANC booking and commencement of iron supplementation, as well as adequate nutrition education for pregnant women. To identify barriers preventing optimal use of iron supplements by pregnant women, eight focus group discussions (FGD) were conducted, with 64 women, aged 17-39 years. Major barriers preventing the optimal use of iron supplements included erratic supplies at healthcare centres, cultural and religious influences and side-effects associated with supplements and poverty. Ignorance due to inadequate nutrition education and poor communication between nurses and pregnant women, were other notable barriers. The erratic availability of iron supplements at the healthcare centre resulted in many women not taking supplements because they could not afford to buy them from private pharmacies. However, in the few instances when supplies were available at healthcare centres, some women collected iron supplements but did not use them, while some managed to use the supplements consistently. Therefore, continuous reinforcement of positive supplementation practices is recommended to motivate for compliance among pregnant women. Adequate nutrition education and counselling is necessary for promoting awareness regarding the importance of iron supplements, dietary diversity and management of side-effects. Improvements in the procurement and delivery system at a national level will help to ensure timeous provision of iron supplements to healthcare centres. Sixty-seven pregnant women in their second and third trimesters were purposively sampled to participate in eight FGDs on the development of a nutrition education tool. Pregnant women gave their views on the nutrition education tool they most preferred and the most appropriate language and information to include. The pregnant women indicated that a pamphlet was the most preferred form of nutrition education tool, with English as the preferred main language of communication, along with some Shona phrases for clarification. Three extra FGDs were conducted with 28 pregnant women to test the developed nutrition education tool for acceptability and user-friendliness by pregnant women. It was found that good use of images which are culturally sensitive, appropriate use of colours, and labelling foods in both English and Shona enhanced the identification of foods, thus improving acceptability of the developed pamphlet. Earlier results obtained from both nurses and pregnant women revealed that most pregnant women did not receive adequate nutrition education on the importance and use of iron supplements during pregnancy, leading to poor compliance. Late ANC bookings at healthcare centres affected the initiation of iron supplementation. Thus, the development of a nutrition education tool for use by pregnant women could enhance knowledge on the importance of iron supplementation, since most women had inadequate nutrition knowledge. Intensive nutrition education programmes, routine iron supplementation and use of the developed nutrition education pamphlet are recommended to reduce the prevalence of IDA among pregnant women in Zimbabwe. This study has shown that issuing iron supplements without an accompanying nutrition education tool may not effectively alleviate maternal IDA. Poor compliance with iron supplementation regimens remains a challenge because of several barriers, which also include inadequate baseline knowledge among pregnant women. Therefore, the development of a nutrition education tool is a positive move towards improving compliance, especially if the tool is offered to pregnant women timeously. The study has indicated that the tool may likely enhance understanding by consolidating nutrition education conducted at healthcare centres and iron supplements given to pregnant women. However, erratic supplies of supplements remains a challenge, as well as delayed ANC bookings by many pregnant women. Thus, this study has shown that offering a nutrition education pamphlet along with iron supplements, has the potential to create awareness and motivate towards compliance with iron supplements. This has the potential to reduce the prevalence of maternal IDA amongst pregnant women in Zimbabwe and sub-Saharan Africa.