JRHS 2008; 8(1): 39-45

Copyright © Journal of Research in Health Sciences

Predicting Factors in Iron Supplement Intake among Pregnant Women in Urban Care Setting

Yekta Z (PhD)a, Ayatollahi H (PhD)b , Pourali c,  Farzin Ad

a Department  of Community Medicine, Faculty of Medicine, Urmia  University of Medical Sciences, Urmia, Iran

b Department  of Gynecology, Urmia University of Medical Sciences, Urmia, Iran

c Instructor of Health Education. Department of Community Medicine, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran

d Resident of Pediatric. Department of Pediatric, Cincinnati, US

*Corresponding author: Dr. Zahra Yekta, E-mail: yekta42@yahoo.com

Received: 12 October 2007; Accepted: 22 December 2007


Background: The world health organization estimates that 58% of pregnant women in developing coun­tries are anemic. In spite of the fact that most ministries of health in developing countries have policies to provide pregnant women with iron supplementation, prevalence of maternal anemia has not declined sig­nificantly. The aim of this study was to assess adherence to the current recommendation in the local popu­lation and to describe factors associated with taking iron supplementation during pregnancy.

Methods: A questionnaire assessing the use of prenatal iron supplementation was distributed among women recently having delivered in Urmia, west Azerbaijan Province, northwest Iran. The question­naire consisted of two sections. The first included demographic information and the second part cov­ered questions regarding duration of iron supplementation, awareness of per partum anemia and manage­ment including benefits and side effects of iron supplementation. SPSS version 10 was used for sta­tistical analysis; data were analyzed by Chi-Square and logistic regression.

Results: Eighty seven percent of participants took iron supplements for at least 4 months. Training dur­ing pregnancy was associated with longer duration of iron use. In logistic regression analysis nulipar­ity was the only variable, which remained in the model .Knowledge of participants on anemia, was obviously poor. Health care stuffs were the main source of information.

Conclusion: The compliance was rather high but knowledge of subjects was low.  Therefore, increas­ing effort is required to mobilize health workers to distribute information on anemia prevention and us­ing iron supplements properly.

Keywords: Pregnancy, Iron supplement, Compliance, Iran


Iron deficiency anemia (IDA) is one of the most frequently observed nutritional de­fi­cien­cies among pregnant women in develop­ing countries (1). The World Health Organiza­tion estimates that the worldwide prevalence of IDA among pregnant women is almost 55.8% (2). IDA is also an impor­tant risk factor in maternal morbidity and re­sults in decreased work capacity (1).

In the Eastern Mediterranean Region (EMR) collected data indicates 149 million people are iron-deficient or anemic accord­ing to the WHO criteria, with 83 million of this population suffering from resulting ane­mia (3).

To reduce IDA, at least 49 countries have im­plemented iron supplementation programs (4). Majority of health ministries in develop­ing coun­tries have policies to provide preg­nant women either iron by itself, combined with folate or in prenatal vitamins (5). How­ever, only a few countries have reported sig­nificant improve­ment in anemia rates at the na­tional level (1- 10). This could be due to sev­eral constraints such as poor infrastruc­ture of the health care system (4), lack of moti­vation of health care workers, limited in­formation on the effec­tiveness of supplementa­tion interventions in health stuff (11), incomplete compliance due to side ef­fects (12) and lack of awareness of IDA among pregnant women (1, 13).

Accordingly, IDA is a serious public health is­sue among pregnant women in the Islamic Republic of Iran, with a prevalence of 2.4 to 27.8% in various parts of the country (6-9) de­spite national Public Health Center recom­mendations regarding regular iron supple­men­tation during pregnancy. The aim of this study was to assess adherence to the cur­rent recommendations and to describe fac­tors as­sociated with taking iron supple­ment during pregnancy.


This study was conducted in Urmia, north­west of Iran in 2005. Our sample was chosen according to Public Health Center (PHC) divi­sions. Eight PHC were selected ran­domly among the 28 centers in Urmia.  Twenty-five post-partum women with a child between ages 3 to 6 months were re­cruited from each center.

All subjects were healthy including no medi­cal illnesses or compilations during their preg­nancy. They all received standard prena­tal care by health care staff. All subjects were informed their confidentiality would be maintained and their participation would be voluntary. All women provided consent to take part in the survey.

The ministry of health policy in Iran is to pro­vide 30 mg ferrous sulfate daily from 20 week of gestational age until 3 months after delivery. A questionnaire addressing the use of prenatal iron supplementation was util­ized. Two interviewer gathered information by face-to-face interviews and based on womens self-report. The questionnaire con­tained two sections: The first included demo­graphic information including age, par­ity educational levels. The second part of the survey inquired about duration of iron intake (How long did you take iron supplement dur­ing pregnancy?), associated side effects (Did you experience any side effects of iron supplement? Which one), awareness of ane­mia and benefits of iron use (which one is cor­rect: -Increased requirement is cause of anemia during pregnancy. -Meat is one of the iron rich foods. -Taking iron tablet is to prevent anemia. -Difficulty pregnancy is con­sequence of anemia. -Unhealthy child and mother is consequence of anemia), man­agement of side effects (what did you do when you experienced side effects), and rea­sons for discontinuation of iron intake (Did you consult with anyone when you decided dis­continuing iron supplement). Subjects were also questioned regarding their primary source of information (Advice on iron intake being told by: 1- health worker 2- women's union 3-Radio /Tv 4- physician).

Among compliant patients, duration of iron supplementation was classified into two groups of iron intake for 1 to 4 months or “shorter duration” in comparison to 5 to 9 months or “longer duration”. 

This division of timing is based on the litera­ture report that 12 wk of iron supplementa­tion is sufficient to produce a maximal hemoglobin response (14, 15) where the compliance was 100%. However, be­cause in the real world compliance is never 100%, four months of iron supplementa­tion was set as the criteria for suc­cess. In a comprehensive review of ran­domized control trials on the prenatal iron sup­plementation, the optimal duration of tak­ing iron tablets remains unclear (16).

All data from questionnaires were coded and entered into SPSS software for analysis.  Ini­tially descriptive statistics were obtained and t-test was used to compare mean of taking iron according to some variables including par­ity (nuliparous), age (less than 25), and educational levels.

The association between longer duration with independent variables was assessed with Chi Square. Then odds ratios were cal­culated by using binary logistic regression analysis to evaluate the association between du­ration of taking iron and relevant predictor factors including demographic characteristic, knowledge on anemia and experiencing of side effects.


The socio-demographic characteristics of sam­ple are detailed in Table 1. In this study, the mean duration of taking iron tablets was 5.9±1.7 (min: 1, max: 8 months).

In summary, 30.3% of subjects experienced side effects of iron with vomiting reported as the most prevalent problem.  Only 54.9% of participants reported training regarding iron benefits and side effects during pregnancy.  Although the mean duration of iron use was higher significantly in subjects who received training and nuliparous women (6.2 vs. 5.6 and 6.6 vs5.7 respectively), other variables such as demographic factors and experienc­ing side effects did not show any differences (Table 1).

Table 1: The mean ±SD duration of taking iron ac­cording to independent variables





Age 24

Age 25






Did not complete high school

High school and above

















Experience side effect






Four months of iron supplementation use was set as criteria of success (14-16). Ac­cording to this categorization, 13% of women took iron tablets for 1-4 months (shorter duration) and 87% used supple­ments for 5-9 month (longer duration) during their last pregnancy.

We also assessed high compliance of iron tab­lets (longer duration: taking 5-9 Months) with some independent variables. Training and nuliparous subjects showed a significant association with longer duration of iron use (P<0.05). Factors that may influence of tak­ing iron tablets were compared between shorter and longer duration groups in Table 2.

Table 2: Comparison of variables that affect duration of taking iron tables


Shorter Duration (%) (n=24)

Longer Duration (%)

n (160)











Experience side effects












The odds ratio for longer period of taking iron tablets (5-9 months) was significantly asso­ci­ated with multiparty after entering vari­ables with a forward stepwise procedure (odds ratio= 1.58 95%CI: 1.15-4.89,  P< 0.05), (Table 3).

Table 3: Remaining variables in Logistic regression analysis with forward stepwise procedure













Experience side effects












The main informational source of anemia and benefits of iron supplementation were health workers (67%) versus other sources like private centers and media. Knowledge was obviously insufficient regardless to du­ra­tion of taking iron tablets. For example, only 3% of participants had been advised on management of side effects.

The participants with low compliance (less than 4 months had been interviewed for some reasons encourage them to discontinue iron use, 87% of them believe iron tablets are not necessary for maternal-fetal health and that it can be provided by food, and 13% did not mention any significant attitude re­garding iron use and stopped using just be­cause of their relatives recommendation.


Iron deficiency anemia is a problem of seri­ous public health; it is the most common nutri­tional disorder in the world, as it is in the eastern Mediterranean region (3). In the de­veloping world, 47% of pregnant women in Africa, 39% in Latin America, 80% in Southeast Asia, 65% in the Eastern Medi­terra­nean, and 40% of pregnant women in the West Pacific are believed to be anemic (17). The prevalence of anemia among preg­nant women is different in different parts of Iran with a range between 2.8% in Hamadan to 27.5% in Jahrom indicating the signifi­cance of socio-economic status, culture, in­cluding nutritional beliefs and life style in overall prevalence of anemia (6-9, 13). 

Iron supplementation is probably the best avail­able option to effectively address iron de­ficiency in pregnant women and young chil­dren (3).

Available literature from several countries sug­gest that the most important reason for the failure of supplementation programs is a lack of supply (18), but noncompliance on the part of pregnant women can also be a sig­nificant factor. Low compliance is the re­sult of an aversion to the side effects of tak­ing iron supplements and the failure of many primary health care systems to adequately mo­tivate both health cares providers and preg­nant women regarding significance of iron intake (18).

This study found that the compliance was rather high but knowledge of subjects was low. Results from various studies show con­sumer knowledge about anemia is low.  How­ever, when consumers are informed, the compliance rate for taking iron tablets in­creases (11).In the present study the average duration of taking iron was significantly higher among subjects who received training (6.3+-1.5 vs. 5.6+-1.6).

Information, education and communication (IEC) programs are the best approach to im­prove the effectiveness of iron intervention (1, 11).

It is reported that anemia prevalence de­creased in Thailand when village health volun­teers made more effort to encourage pregnant women to attend antenatal care ser­vices (10).

One of the difficulties in program manage­ment for anemia reduction was the low level of awareness among the target population and perhaps the negative perception towards iron supplementation among general popula­tion (1). In the present study we found most women received information on anemia and iron supplement from health workers rather than other informational sources such as me­dia, but their knowledge was still low regard­less of the training.

Unfortunately, consumer ignorance is caused in part by health providers limitations, includ­ing lack of knowledge about anemia and iron tablets and insufficient communica­tion and counseling skills (11). Therefore im­proving health providers knowledge and communicational skills has been effective in promoting program content and counseling strategies (11).

Nordeng et al. has reported demographic fac­tors as associated with non-compliance to guideline on iron supplementation during preg­nancy (19).

In this study, no impact was identified by any socio demographic characteristics on taking iron tablets for longer period except par­ity. Nulliparous women took iron longer time, perhaps because of focused training or their reception to accept health workers rec­ommendation as reported by Aikawa et al. (1).

In the present survey, compliance with sup­plementation was relatively high (87%), and few self-reported side effects were reported (30.3%). The study in Jakarta concluded com­pliance of supplementation program was low and the supplementation strategies need reliable monitoring and evaluation system (20). Galloway et Al. showed a high compli­ance (88%) and low side effects (4%) in their study. Another study revealed only one third of women reported that they experi­enced negative side effects (5).

In Sweden, side effects of supplements, per­ceived need and advice from midwives influ­enced on their use (21).

Contrary to the belief that women stop tak­ing iron tablets mainly due to negative side ef­fects (5), in our study experiencing side ef­fect did not influence duration of iron intake. During iron supplementation trials in five countries, only about one tenth of the women stopped taking the tablets due to side effects (5). Another study revealed that gastro­intestinal side effects were not signifi­cantly associated with compliance (22).

There is no doubt that supplementation is re­quired for pregnant women, however the chal­lenge remains to improve the effective­ness of supplementation strategies in many de­veloping countries (23). Limitation of our study findings include the use of self-report data, another point is that it is the popula­tion-based survey in a representative primary care settings not in a general population. We also suggest preparing a study to confirm self-report data with laboratory finding such as serum iron level.

Conclusively, in Iran, iron supplementation programs have been a major strategy to re­duce IDA in Pregnancy and the dynamic na­ture of nutrition problems confirm strategies require regular review to maintain and im­prove their effectiveness.


This work was supported by Urmia Univer­sity of Medical Sciences and Deputy of Health in Urmia. The authors declare that they have no competing interest.


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