Hostname: page-component-7c8c6479df-nwzlb Total loading time: 0 Render date: 2024-03-27T02:50:44.671Z Has data issue: false hasContentIssue false

Community-based distribution of iron–folic acid supplementation in low- and middle-income countries: a review of evidence and programme implications

Published online by Cambridge University Press:  24 October 2017

Justine A Kavle*
Affiliation:
Maternal and Child Survival Program (MCSP), 455 Massachusetts Ave. NW, Suite 1000, Washington, DC 20036, USA PATH, Maternal, Newborn, Child Health and Nutrition, Washington, DC, USA Department of Prevention and Community Health, The George Washington University, Milken Institute School of Public Health, Washington, DC, USA
Megan Landry
Affiliation:
Department of Prevention and Community Health, The George Washington University, Milken Institute School of Public Health, Washington, DC, USA Independent Consultant, PATH, Washington DC, USA
*
*Corresponding author: Email jkavle@path.org
Rights & Permissions [Opens in a new window]

Abstract

Objective

The present literature review aimed to review the evidence for community-based distribution (CBD) of iron–folic acid (IFA) supplementation as a feasible approach to improve anaemia rates in low- and middle-income countries.

Design

The literature review included peer-reviewed studies and grey literature from PubMed, Cochrane Library, LILAC and Scopus databases.

Setting

Low- and middle-income countries.

Subjects

Non-pregnant women, pregnant women, and girls.

Results

CBD programmes had moderate success with midwives and community health workers (CHW) who counselled on health benefits and compliance with IFA supplementation. CHW were more likely to identify and reach a greater number of women earlier in pregnancy, as women tended to present late to antenatal care. CBD channels had greater consistency in terms of adequate supplies of IFA in comparison to clinics and vendors, who faced stock outages. Targeting women of reproductive age through school and community settings showed high compliance and demonstrated reductions in anaemia.

Conclusions

CBD of IFA supplementation can be a valuable platform for improving knowledge about anaemia, addressing compliance and temporary side-effects of IFA supplements, and increasing access and coverage of IFA supplementation. Programmatic efforts focusing on community-based platforms should complement services and information provided at the health facility level. Provision of training and supportive supervision for CHW on how to counsel women on benefits, side-effects, and when, why, and how to take IFA supplements, as part of behaviour change communication, can be strengthened, alongside logistics and supply systems to ensure consistent supplies of IFA tablets at both the facility and community levels.

Type
Review Articles
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http:// creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © The Authors 2017

Globally, anaemia affects 29 % of pregnant women and 38 % of non-pregnant women( Reference Stevens, Finucane and De-Regil 1 ) and is associated with one-fifth of maternal deaths( Reference Black, Allen and Bhutta 2 ). Anaemia puts women at greater risk of mortality, morbidity, postpartum haemorrhage and poor birth outcomes, including preterm births and low birth weight( Reference Kavle, Stoltzfus and Witter 3 , Reference Rahman, Abe and Rahman 4 ). The WHO recommends daily iron–folic acid (IFA) supplementation (30–60 mg iron, 0·4 g folic acid) initiated as early as possible and continued throughout pregnancy for all adolescent and adult women as a key intervention to reduce the risk of maternal anaemia, iron deficiency and infants born with low birth weight( 5 ). According to findings from a recent meta-analysis, IFA supplementation would increase the mean blood Hb concentration by 10·2 (95 % CI 6·1, 14·2) g/l in pregnant women and by 8·6 (95 % CI 3·9, 13·4) g/l in non-pregnant women (aged 19–21 years)( 6 ). Applying these shifts to estimated blood Hb concentrations indicates that about 50 % of anaemia in women could be eliminated by IFA supplementation( 6 ).

A secondary analysis of national Demographic and Health Survey data sets in nineteen African countries found that when pregnant women received at least ninety IFA supplements through antenatal care (ANC), the risk of neonatal mortality decreased by 34 %( Reference Titaley, Dibley and Roberts 7 ). Similar findings were shown in Nepal, as neonatal mortality decreased by 45 % in the first week and 42 % in the first 28d when women started taking IFA supplements in their first trimester of pregnancy, or if they took at least 150 IFA supplements during their pregnancy( Reference Nisar, Dibley and Mebrahtu 8 , Reference Nisar and Dibley 9 ).

Despite these benefits of maternal IFA supplementation, many low- and middle-income countries continue to face high anaemia rates( Reference Black, Victora and Walker 10 , 11 ). Interventions delivered at the health facility level, such as IFA supplementation, are not operating at scale in most countries due to lack of demand from health sectors and beneficiaries (e.g. low ANC attendance), limited funding, stock outages and ineffective management of supplies( Reference Christian, Shrestha and LeClerq 12 Reference Trowbridge and Martorell 15 ).

Although these findings reveal the benefits of IFA supplementation for anaemia and neonatal outcomes, more information is needed on best practices and the most effective strategies to deliver IFA supplementation through community-based channels to complement ANC, since access and supply are issues( Reference Christian, Shrestha and LeClerq 12 Reference Trowbridge and Martorell 15 ). In the present review, we examine evidence for community-based distribution (CBD) of IFA supplementation as a feasible approach to improve anaemia rates in low- and middle-income countries.

Design and methods

An extensive literature review of peer-reviewed and grey literature on CBD of IFA supplementation for pregnant women and women of reproductive age (WRA) was conducted. This search strategy was developed and reviewed by the authors and included the following keywords in various combinations: ‘community based distribution’ & ‘IFA’, ‘iron–folic acid’ & ‘community health workers’, ‘CBD of IFA’, ‘iron–folic acid’ & ‘community level’, ‘IFA’ & ‘community utilization’ and/or ‘community’ & ‘iron–folic acid supplements’. We searched published literature, including quantitative, qualitative and mixed-methods studies, from PubMed, Cochrane Library, LILAC and Scopus databases. The initial search returned 147 articles, which were reviewed to determine eligibility for inclusion. Inclusion criteria included studies published between the years of 2000 and 2015 and studies which reported a community element and/or community-based distribution of IFA supplements that described at least one of the following components of programme implementation: type of health worker, supply and demand issues, coverage within the community, and strategies to improve IFA supplementation coverage and utilization for pregnant women and WRA in low- and middle-income countries. CBD of IFA supplementation was reported through various platforms, including private pharmacies within communities, community health centres, home visits from health workers and community gatherings for health education sessions. The type of worker/distributor at the community level varied and included midwives, community health workers (CHW), volunteer health workers, mobile health workers from local health centres, village youth volunteers and pharmacists.

One author reviewed and screened titles and abstracts to determine initial inclusion, while the other author confirmed the final articles for the review. This resulted in a final pool of twenty-two articles with findings from Ending Preventable Maternal and Child Deaths (EPCMD)Footnote * priority countries, including Bangladesh, India, Kenya, Mali, Nepal, Pakistan, Senegal and Tanzania, as well as findings from other countries: Cambodia, Iran, Philippines, Tibet and Vietnam (see Table 1). Excluded articles were those without a community component (e.g. IFA supplementation strictly at the health facility level) and reviews of previous programmes (e.g. systematic reviews of programme evaluations).

Table 1 Summary of key findings from articles included in the present review of community-based distribution of iron–folic acid supplementation in low- and middle-income countries

IFA, iron–folic acid; ANC, antenatal care; CHW, community health workers; WRA, women of reproductive age; LBW, low birth weight.

Results

Strengths of community-based distribution of iron–folic acid supplementation

Community-based distribution of iron–folic acid supplementation is a valuable platform to increase awareness and knowledge of anaemia and iron–folic acid supplementation

Seven studies reported on increased knowledge and coverage of IFA supplementation through provision of messages and counselling on anaemia and IFA supplementation through community-based channels( Reference Alam, Rasheed and Khan 17 Reference Yekta, Ayatollahi and Pourali 23 ). A study from Iran found that CHW provided counselling on the importance of taking IFA supplements for reducing anaemia. Due to increased awareness and knowledge, pregnant women who received messages from CHW about the benefits of IFA supplementation and potential side-effects adhered to IFA supplements for a significantly longer duration (5–9 months) than women who did not receive messages( Reference Yekta, Ayatollahi and Pourali 23 ). Another study in Cambodia, which reported on the implementation of a weekly IFA supplementation government programme with secondary-school girls (n 423), women employed in garment factories (n 478) and rural women (n 639), showed substantial improvements in knowledge about the causes, consequences and prevention of anaemia following promotion through social marketing strategies( Reference Kanal, Busch-Hallen and Cavalli-Sforza 18 ). The programme consisted of public broadcasts, billboards, CHW visiting residents, and programme-related T-shirts and bags distributed to community residents.

A government and private-sector pilot project in Vietnam, which employed community-based social mobilization and social marketing approaches in sites supported by volunteer village health workers, government health facility workers and non-governmental organizations, demonstrated significant increases in the percentage of women with awareness that ‘poor nutrition led to anaemia’, that ‘weekly iron–folic acid supplementation could help to prevent anaemia’, of the need for ‘more iron during pregnancy’ and the role of hookworm infection as a cause of iron-deficiency anaemia (P<0·001). The percentage of women who recognized the health effects of anaemia and the health benefits of taking an IFA supplement also increased significantly (P<0·001)( Reference Khan, Thanh and Berger 24 ). Another study in India registered community-level medical practitioners, increased distribution of IFA tablets, and provided women with correct information and messages about consuming IFA tablets. Programme results indicated an increase in awareness of anaemia at the endline survey to more than 90 % of women, which nearly doubled from the baseline figure (49·2 %). In addition, knowledge that taking IFA supplements during pregnancy can prevent anaemia increased significantly from 12·9 % at baseline to 51·5 % at the endline survey( Reference Srivastava, Kotecha and Singh 22 ).

Qualitative data from a study in Pakistan illustrated the value of CBD of IFA supplementation as a platform for communicating the benefits of IFA supplements. One rural mother in Pakistan described her experience: ‘These tablets are good to provide strength to our bodies which are weak during the pregnancy, and also improve the feeling of dizziness; these tablets are good for my health’( Reference Nisar, Alam and Aurangzeb 19 ). In other country contexts such as Bangladesh, India and Senegal, where women received IFA supplements through community channels such as pharmacists and village health workers, women relayed how taking IFA tablets had improved health benefits such as increasing blood volume, leading to fetal nourishment and compensation for blood loss during delivery( Reference Alam, Rasheed and Khan 17 , Reference Pal, Sharma and Sarkar 20 , Reference Seck and Jackson 21 ). In agreement with these studies, in Mali, mothers who received community-based IFA supplementation messages discussed their experience with taking IFA supplements: ‘I feel healthy’, ‘I feel good’ or ‘I don’t fall sick’, ‘the baby is/stays healthy’ and ‘the baby breast-feeds well/a lot/frequently’( Reference Aguayo, Koné and Bamba 25 ).

Community-based distribution of iron–folic acid supplementation can encourage attendance to antenatal care

CBD of IFA supplementation can also be an important mechanism to complement ANC, to encourage early and frequent attendance at ANC, and to achieve the WHO recommendation of at least four visits during pregnancy. Late presentation to ANC, in the second or third trimester, and utilization of health services is a key challenge to maternal IFA supplementation provided through ANC( Reference Yekta, Ayatollahi and Pourali 23 , Reference Khan, Thanh and Berger 24 , Reference Nisar, Dibley and Mir 26 , Reference Wendt, Stephenson and Young 27 ). For example, in the Philippines, the first prenatal visit occurred at 3·80 (sd 1·56) months and mothers averaged less than one visit per month after the initial visit( Reference Lutsey, Dawe and Villate 28 ). Similarly, in another study conducted in Pakistan, maternal IFA supplementation was initiated, on average, in the fifth month of pregnancy, and only 5 % of women presented to ANC and received IFA supplements during their first trimester of pregnancy( Reference Nisar, Dibley and Mir 26 ). Moreover, one-third of participants in Pakistan did not use ANC services at all during their last pregnancy.

In Pakistan, the Philippines, Nepal, Tanzania and Thailand, distribution of IFA supplementation through community-based channels, such as CHW and various women’s social networks, was found to reach a greater proportion of women compared with ANC( Reference Alam, Rasheed and Khan 17 , Reference Yekta, Ayatollahi and Pourali 23 , Reference Nisar, Dibley and Mir 26 , Reference Young, Ali and Beckham 29 ). Six studies found that CBD of IFA supplementation can increase ANC attendance through community agents encouraging earlier and consistent ANC visits( Reference Aguayo, Koné and Bamba 25 , Reference Nisar, Dibley and Mir 26 , Reference Lutsey, Dawe and Villate 28 , Reference Angeles-Agdeppa, Paulino and Ramos 30 Reference Ndiaye, Siekmans and Haddad 32 ). In Nepal, a programme with community volunteers that distributed IFA supplements found a substantial increase in compliance (defined as those taking 80 % of the recommended number of supplements) and increased ANC attendance through community volunteers, which dispelled a common local belief that community distribution would discourage women from seeking care at health facilities( Reference Pandey, Maharjan and Thapa 33 ).

Community-based distribution of iron–folic acid supplementation can increase compliance and address side-effects

Fourteen( Reference Alam, Rasheed and Khan 17 , Reference Kanal, Busch-Hallen and Cavalli-Sforza 18 , Reference Pal, Sharma and Sarkar 20 , Reference Seck and Jackson 21 , Reference Khan, Thanh and Berger 24 , Reference Aguayo, Koné and Bamba 25 , Reference Wendt, Stephenson and Young 27 , Reference Lutsey, Dawe and Villate 28 , Reference Dickerson, Crookston and Simonsen 31 , Reference Dickerson, Crookston and Simonsen 34 Reference Shivalli, Srivastava and Singh 37 , Reference Mora 39 ) of twenty-six studies identified CBD platforms as being successful in addressing factors related to compliance, such as maintaining the daily regimen of one pill per day, temporary side-effects (e.g. vomiting, nausea, dizziness) and forgetfulness. In addition, eight studies reported that more than 75 % of women had high compliance (taking ≥70 % of tablets) with IFA supplementation when there was a consistent supply of IFA supplements from the community level, either with or without IFA supplements delivered through health facilities( Reference Seck and Jackson 21 , Reference Khan, Thanh and Berger 24 , Reference Aguayo, Koné and Bamba 25 , Reference Lutsey, Dawe and Villate 28 , Reference Bharti 34 Reference Shivalli, Srivastava and Singh 37 ).

In India, compliance was higher (62 %) among mothers who were counselled by health workers on when, how and why IFA supplementation is important than among those who did not receive guidance( Reference Pal, Sharma and Sarkar 20 ). In Vietnam, a free monthly distribution of IFA supplements indicated that 85 % of WRA achieved full or partial compliance (defined as taking some but not all tablets) to weekly IFA supplementation through the existing health service infrastructure (e.g. health clinics and facilities) with village health workers as the direct point of contact; and included training for village health workers on anaemia, IFA supplementation and deworming( Reference Phuc, Mihrshahi and Casey 36 ). In a randomized study in Senegal, midwives were a strong motivator for improved IFA supplementation compliance in the treatment group (86 %) v. the control group (48 %; P<0·0001), as midwives encouraged women to take IFA tablets by influencing their perceptions that IFA tablets would improve health and reduce anaemia( Reference Seck and Jackson 21 ).

In addition to the findings above, seven studies described the use of social marketing, counselling and health education methods, in combination with CBD, to increase access and compliance to IFA supplementation( Reference Alam, Rasheed and Khan 17 , Reference Kanal, Busch-Hallen and Cavalli-Sforza 18 , Reference Khan, Thanh and Berger 24 , Reference Aguayo, Koné and Bamba 25 , Reference Wendt, Stephenson and Young 27 , Reference Dickerson, Crookston and Simonsen 31 , Reference Garcia, Datol-Barrett and Dizon 38 ). In Vietnam, rates of buying and consuming a weekly IFA supplement for WRA in programme sites were 55 and 92 %, respectively. High rates were attributed to increased knowledge from community-based social marketing and mobilization( Reference Khan, Thanh and Berger 24 ). In another study carried out in Pakistan, lady health workers, who conduct routine home visits, positively influenced increased consumption of IFA supplements, as 19 % of women residing in programme areas consumed ninety or more tablets, compared with only 12 % in non-programme areas( Reference Nisar, Dibley and Mir 26 ).

Community workers aided women to comply with IFA supplementation throughout pregnancy through home visit reminders, as forgetfulness to take the supplements on a daily basis was reported as a primary reason for non-compliance in settings such as India, Mali, Pakistan, the Philippines and Senegal( Reference Nisar, Alam and Aurangzeb 19 , Reference Seck and Jackson 21 , Reference Aguayo, Koné and Bamba 25 , Reference Lutsey, Dawe and Villate 28 ). Five studies circumvented forgetfulness by utilizing village health volunteers to encourage mothers to use ANC and visiting homes to provide reminders for taking pills( Reference Pal, Sharma and Sarkar 20 , Reference Dickerson, Crookston and Simonsen 31 , Reference Bharti 34 Reference Phuc, Mihrshahi and Casey 36 ). Moreover, in India, Tibet and Nicaragua, community health volunteers and other community-level workers delivered supplements and provided clients with follow-up counselling, which helped women understand how to address potential and temporary side-effects such as vomiting, nausea and dizziness( Reference Srivastava, Kotecha and Singh 22 , Reference Dickerson, Crookston and Simonsen 31 , Reference Mora 39 ). These strategies often resulted in significantly higher IFA supplement consumption among mothers who received an explanation on IFA supplements from CHW compared with those who were not provided information by the health worker (χ 2=4·529; P<0·05)( Reference Pal, Sharma and Sarkar 20 ).

Barriers to successful roll-out of community-based distribution of iron–folic acid supplementation

Advice from influential family and community members

Four articles identified advice from influential family members as a barrier to consumption of the IFA supplements( Reference Alam, Rasheed and Khan 17 , Reference Nisar, Alam and Aurangzeb 19 , Reference Srivastava, Kotecha and Singh 22 , Reference Yekta, Ayatollahi and Pourali 23 ). One woman reported her mother-in-law’s response when she perceived the iron tablets were causing her to feel ill: ‘I used these [IFA] tablets but after few days I had vomiting and diarrhoea with these [supplements] and my mother-in-law told me to stop this medicine; she [mother-in-law] told me not to take any medicine during pregnancy’( Reference Nisar, Alam and Aurangzeb 19 ). Similarly, in Iran, although most women adhered to IFA for a 5–9-month period, 13 % of women surveyed stopped taking IFA supplements early, because relatives advised them to stop( Reference Yekta, Ayatollahi and Pourali 23 ). CBD can be used to help alleviate potentially negative advice from family members. Using an example from Tibet as to how programmatically this can be achieved, the Pregnancy and Village Outreach Tibet (PAVOT) programme conducted comprehensive community and home-based maternal newborn and nutrition outreach to rural pregnant women and family members on anaemia and IFA supplementation, as well as antenatal/postpartum care, birth planning, danger sign recognition, clean and safe delivery practices, and breast-feeding( Reference Dickerson, Crookston and Simonsen 31 ). The PAVOT programme included training of master trainers, who then trained outreach providers comprising laypersons and health-care workers, through role playing, hands-on skills, and distribution of IFA supplements and counselling on their use. Skills included identification of barriers and solutions to reinforce key messages to women and their families. The programme reported that 68 % of programme participants, consisting of pregnant women and family members, received three or more home visits by CHW that entailed counselling and support to address seeking ANC early, antenatal nutrition, micronutrient supplementation and safe delivery practices( Reference Dickerson, Crookston and Simonsen 31 ). Through the programme, 99 % of pregnant women received IFA supplements, but the programme did not assess compliance to IFA supplementation( Reference Dickerson, Crookston and Simonsen 31 ).

Supplies of iron–folic acid supplements: availability at health facilities v. community

Unavailability of IFA tablets at local health facilities was cited as a barrier to compliance in four articles( Reference Srivastava, Kotecha and Singh 22 , Reference Aguayo, Koné and Bamba 25 Reference Wendt, Stephenson and Young 27 ), and seven articles reported high compliance (above 75 %) to IFA supplementation when there was a consistent supply of IFA supplements available to them( Reference Khan, Thanh and Berger 24 , Reference Aguayo, Koné and Bamba 25 , Reference Lutsey, Dawe and Villate 28 , Reference Bharti 34 Reference Shivalli, Srivastava and Singh 37 ). For example, in India, adequate IFA supplement supply was significantly associated with increased IFA supplement consumption when controlling for demographic variables (OR=1·33; 95 % CI 1·03, 1·71)( Reference Wendt, Stephenson and Young 27 ). Women residing in villages where a health centre had available supplies of IFA supplements were more likely to have consumed IFA tablets for ninety or more days during their last pregnancy (OR=1·37; 95 % CI 1·04, 1·82)( Reference Wendt, Stephenson and Young 27 ).

Findings from a few studies revealed that stock outages at the health facility level were more frequently reported as a barrier than side-effects (e.g. constipation and nausea)( Reference Srivastava, Kotecha and Singh 22 , Reference Wendt, Stephenson and Young 27 ). Community channels, such as private pharmacies, midwives and community agents, were more likely to have consistent supplies of IFA supplements compared with clinics and hospitals, who faced stock outages( Reference Young, Ali and Beckham 29 , Reference Garcia, Datol-Barrett and Dizon 38 ). In one study, it was noted that women will ‘only sometimes’ purchase IFA supplements from a pharmacy with a prescription when community-based lady health workers and/or health facilities faced stock outages of IFA supplements( Reference Nisar, Dibley and Mir 26 ).

Cost in relation to compliance

Six studies reported IFA supplementation was provided free of charge through CBD( Reference Alam, Rasheed and Khan 17 , Reference Nisar, Alam and Aurangzeb 19 , Reference Aguayo, Koné and Bamba 25 , Reference Ndiaye, Siekmans and Haddad 32 , Reference Phuc, Mihrshahi and Casey 36 , Reference Garcia, Datol-Barrett and Dizon 38 ). A few studies assessed the impact of cost in relation to compliance and in relation to purchasing IFA tablets through private pharmacies. In Senegal, a study found significantly higher compliance (86 %) when midwives distributed free IFA tablets to pregnant women after their initial ANC visit at a health facility, compared with women receiving a prescription to purchase the tablets from a private pharmacy or community vendor for $US 0·01 for ten tablets (48 %), indicating that when women are expected to purchase the tablets, compliance may be lessened( Reference Seck and Jackson 21 ). In Cambodia, supplements were sold to women for $US 0·01 for one month’s supply (four tablets) and peer educators went door-to-door to educate and promote the supplements in rural villages, whereas in two other study settings (factories and schools), IFA tablets were provided free of charge. Compliance, defined as adhering to a weekly regimen, as reported by women in each of the three settings, was 55 % for schoolgirls, 57 % for female factory workers and 71 % for rural WRA( Reference Kanal, Busch-Hallen and Cavalli-Sforza 18 ), indicating the sale of tablets, along with the peer education, proved to be the most effective in getting women to consume IFA supplements.

Impact of community-based distribution of iron–folic acid supplementation: coverage and reductions in maternal anaemia

Targeting pregnant women and WRA through community settings demonstrated increased accessibility, high compliance, and reductions in anaemia in thirteen studies( Reference Pal, Sharma and Sarkar 20 , Reference Yekta, Ayatollahi and Pourali 23 , Reference Khan, Thanh and Berger 24 , Reference Aguayo, Koné and Bamba 25 , Reference Lutsey, Dawe and Villate 28 , Reference Angeles-Agdeppa, Paulino and Ramos 30 , Reference Bharti 34 Reference Shivalli, Srivastava and Singh 37 , Reference Casey, Phuc and Macgregor 40 , Reference Seck and Jackson 42 ). Nicaragua increased IFA supplementation coverage among pregnant women to over 80 % and experienced a substantial drop in anaemia prevalence through use of community-based distributors who provided counselling and follow-up to pregnant women( Reference Mora 39 ). A study that applied the Trial of Improved Practices (TIPs) methodology in India aimed to increase positive perceptions of IFA supplementation, IFA supplementation uptake and dietary practices( Reference Shivalli, Srivastava and Singh 37 ). Results of that study indicated that the prevalence of anaemia was reduced by half in the TIPs group and increased by 2·4 % in the control group( Reference Shivalli, Srivastava and Singh 37 ). In Senegal, CBD of iron supplements, alongside implementation of monthly healthy pregnancy promotion sessions delivered via community volunteers, improved accessibility and significantly reduced anaemia prevalence from 85 to 55 % between baseline and endline (P<0·0001) in the positive deviant intervention group, which was significantly different from the control group not receiving the positive deviant approach (P=0·003)( Reference Ndiaye, Siekmans and Haddad 32 ).

In another study, a free weekly IFA supplementation programme in Vietnam assessed effects on anaemia levels. Weekly IFA supplementation and four monthly deworming tablets were distributed through the existing health structure, where all WRA were encouraged to collect packs of four ferrous sulfate/folic acid tablets (60 mg/0·4 mg) from their village health worker each month( Reference Casey, Phuc and Macgregor 40 ). At 3 months post-implementation, anaemia reduced to 5·9 % (relative risk=0·43; 95 % CI 0·26, 0·70; P=0·001); and after 12 months, anaemia levels were further reduced to 4·5 % (relative risk=0·32; 95 % CI 0·15, 0·68; P=0·003)( Reference Casey, Phuc and Macgregor 40 ). Similarly, a community-based programme in India reported a significant overall decrease in anaemia between baseline and endline from 72·6 to 50·7 % (P<0·001) through the use of registered medical practitioners at the community level to provide women with information, tablets and messaging around consuming IFA tablets( Reference Srivastava, Kotecha and Singh 22 ).

Discussion

To our knowledge, the present review is the first which has assessed the effectiveness, strengths and challenges of CBD of IFA supplementation via a programmatic perspective relevant to low- and middle-income countries. The strength of the review lies in the compilation of data on CBD of IFA supplementation as a valuable and potential platform for reducing anaemia and increasing ANC coverage and access, which included increases in awareness and knowledge, compliance and coverage of IFA supplementation for pregnant women and WRA. CBD of IFA supplementation showed success in reducing anaemia with community-based health workers or volunteers who counselled on health benefits, side-effects and compliance with IFA supplementation. These findings are consistent with other research that found community-level workers or volunteers to be instrumental in educating women about common side-effects and how to manage side-effects in order to increase compliance( Reference Wendt, Stephenson and Young 27 , Reference Emamghorashi and Heidari 41 ).

The present review also highlights that CBD of IFA supplementation is a potential platform for encouraging earlier and frequent attendance at ANC, as community-level workers were more likely to identify and reach a greater number of women earlier in pregnancy because women tended not to present to ANC until after the first trimester( Reference Wendt, Stephenson and Young 27 , Reference Lutsey, Dawe and Villate 28 , Reference Pandey, Maharjan and Thapa 33 ). Thus, targeted community distribution could be a successful strategy to not only encourage women to go for earlier ANC visits, but also to start women on an IFA supplementation regimen earlier in their pregnancy( Reference Young, Ali and Beckham 29 ).

Several potential challenges to CBD of IFA supplementation exist. Women reported IFA tablets were more frequently available from CBD channels, such as community vendors or community workers, as compared with health facilities that face stock outages( Reference Young, Ali and Beckham 29 , Reference Garcia, Datol-Barrett and Dizon 38 ). However, inventory systems would be required to forecast and monitor IFA supplies at the community level. Logistics, storage and distribution of IFA supplements (ninety or more supplements per pregnant woman) could be bulky and cumbersome for community workers to provide during household visits.

Several studies have provided strong recommendations for IFA supplementation to be free of charge at the community and facility levels for increased utilization and compliance( Reference Khan, Thanh and Berger 24 , Reference Phuc, Mihrshahi and Casey 36 , Reference Seck and Jackson 42 , Reference Ugwu, Olibe and Obi 43 ). Our findings indicate that the availability and accessibility of free or low-cost commodities improved the use of antenatal IFA supplements. However, even when free of charge, distribution was still cited as a barrier due to frequent stock outages, and this was consistent with other reviews( Reference Nisar, Alam and Aurangzeb 19 , Reference Galloway, Dusch and Elder 44 ). It was also noted that women who live far from government health clinics or outside the CHW service area have a difficult time obtaining free IFA tablets and often cannot afford to purchase them from a private pharmacy( Reference Nisar, Alam and Aurangzeb 19 ). Private distribution points and pharmacies often have associated costs that may limit accessibility and/or desire for IFA supplements( Reference Angeles-Agdeppa, Paulino and Ramos 30 ). However, some women considered paying for and the price of IFA tablets to be acceptable( Reference Khan, Thanh and Berger 24 ), and others would be willing to purchase the tablets after free distribution programmes ended( Reference Kanal, Busch-Hallen and Cavalli-Sforza 18 ).

Our findings revealed that counselling on IFA supplementation could be strengthened through community-based distributors who provide consistent and clear messages on IFA supplementation, as raising awareness and increasing knowledge of IFA and anaemia are critical. Key factors for successful CBD of IFA supplementation programmes include ensuring adequate supply of the IFA commodities, strengthening mechanisms for CBD to increase access for women, provision of training and supervision for CHW on why, how and when IFA should be given, in addition to preparing mothers on how to manage any potential, yet temporary, side-effects (i.e. constipation, black stool), and promotion of behaviour change communications through culturally relevant key messages and counselling in order to increase demand for and compliance with IFA supplementation( 45 ). Engagement with professional associations, such as local nursing, midwifery and physician associations, may be valuable as stakeholders to promote inclusion of CBD of IFA supplementation in national policies and programmes.

Limitations

The current review has several limitations. Information on the role of governance (i.e. public sector-supported CHW, dedicated policies on CBD of IFA supplementation) in relation to community-based platforms was not collected or provided in the studies included in the review. Information on CBD of IFA supplementation consists only of information provided in the current reviewed studies, which often lacked specific data on the IFA supplementation counselling that was received and seldom reported on the specific messages. Only fourteen studies reported data on compliance with IFA supplementation regimens, and few studies reported programme coverage and impact on anaemia.

Conclusions

CBD of IFA supplementation can be a valuable platform for increasing awareness, improving knowledge, addressing compliance and side-effects, and increasing access and coverage of IFA supplementation. Programmatic efforts should focus on community-based platforms that complement services at the health facility level. Provision of training and supportive supervision for community-level agents on how to counsel women on benefits and side-effects and when, why and how to take IFA supplements, as part of behaviour change communication, should be strengthened, alongside logistics and supply systems to ensure consistent supplies of IFA tablets.

Acknowledgements

Acknowledgements: The authors gratefully acknowledge Allison Gottwalt, who provided support to the extraction of data and editing of this manuscript. Financial support: This work is made possible by the generous support of the American people through the US Agency for International Development (USAID) under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government. USAID had no role in the design, analysis or writing of this article. Conflict of interest: None. Authorship: J.A.K. formulated the research question and directed the literature review. M.L. carried out the literature review and compilation of data, with input from J.A.K. J.A.K. and M.L. jointly wrote the manuscript. Both authors reviewed and approved the final manuscript. Ethics of human subject participation: Not applicable.

Footnotes

* The US Agency for International Development’s (USAID’s) 2014 Acting on the Call Report formulated country-specific plans for working with partners in twenty-four priority countries to save the lives of mothers and children. The follow-up 2015 Acting on the Call Report provided country-by-country progress updates with new recommendations for reaching 38 million women with increased access to high-quality health services around the time of delivery. USAID’s 2016 Acting on the Call Report built on the 2014 and 2015 Reports with new updates and preliminary data on progress made over the past year in twenty-four priority countries and introduced Burma as the twenty-fifth priority country( 16 ).

References

1. Stevens, GA, Finucane, MM, De-Regil, LM et al. (2013) Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995–2011: a systematic analysis of population-representative data. Lancet Glob Health 1, e16e25.CrossRefGoogle ScholarPubMed
2. Black, RE, Allen, LH, Bhutta, ZA et al. (2008) Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 371, 243260.CrossRefGoogle ScholarPubMed
3. Kavle, JA, Stoltzfus, RJ, Witter, F et al. (2008) Association between anaemia during pregnancy and blood loss at and after delivery among women with vaginal births in Pemba Island, Zanzibar, Tanzania. J Health Popul Nutr 26, 232240.Google ScholarPubMed
4. Rahman, MM, Abe, SK, Rahman, MS et al. (2016) Maternal anemia and risk of adverse birth and health outcomes in low- and middle-income countries: systematic review and meta-analysis. Am J Clin Nutr 103, 495504.CrossRefGoogle ScholarPubMed
5. World Health Organization (2012) Guideline: Daily Iron and Folic Acid Supplementation in Pregnant Women. Geneva: WHO.Google Scholar
6. World Health Organization (2015) The Global Prevalence of Anaemia in 2011. Geneva: WHO.Google Scholar
7. Titaley, CR, Dibley, MJ, Roberts, CL et al. (2010) Combined iron/folic acid supplements and malaria prophylaxis reduce neonatal mortality in 19 sub-Saharan African countries. Am J Clin Nutr 92, 235243.CrossRefGoogle Scholar
8. Nisar, YB, Dibley, MJ, Mebrahtu, S et al. (2015) Antenatal iron–folic acid supplementation reduces neonatal and under-5 mortality in Nepal. J Nutr 145, 18731883.CrossRefGoogle ScholarPubMed
9. Nisar, YB & Dibley, MJ (2014) Earlier initiation and use of a greater number of iron–folic acid supplements during pregnancy prevents early neonatal deaths in Nepal and Pakistan. PLoS One 9, e112446.CrossRefGoogle ScholarPubMed
10. Black, RE, Victora, CG, Walker, SP et al. (2013) Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 382, 427451.CrossRefGoogle ScholarPubMed
11. World Health Organization, World Food Programme & UNICEF (2007) Preventing and Controlling Micronutrient Deficiencies in Populations Affected by an Emergency. Geneva: WHO.Google Scholar
12. Christian, P, Shrestha, J, LeClerq, SC et al. (2003) Supplementation with micronutrients in addition to iron and folic acid does not further improve the hematologic status of pregnant women in rural Nepal. J Nutr 133, 34923498.CrossRefGoogle Scholar
13. Pokharel, RK, Houston, R, Harvey, P et al. (2010) Nepal Nutrition Assessment and Gap Analysis. Kathmandu: Nepal Ministry of Health and Population.Google Scholar
14. Sharma, JB, Jain, S, Mallika, V et al. (2004) A prospective, partially randomized study of pregnancy outcomes and hematologic responses to oral and intramuscular iron treatment in moderately anemic pregnant women. Am J Clin Nutr 79, 116122.CrossRefGoogle ScholarPubMed
15. Trowbridge, F & Martorell, R (2002) Summary and recommendations. J Nutr 132, 4 Suppl., 875S879S.CrossRefGoogle ScholarPubMed
16. US Agency for International Development (2016) Acting on the Call: Ending Preventable Child and Maternal Deaths: A Focus on Equity. Washington, DC: USAID.Google Scholar
17. Alam, A, Rasheed, S, Khan, NU et al. (2015) How can formative research inform the design of an iron–folic acid supplementation intervention starting in first trimester of pregnancy in Bangladesh? BMC Public Health 15, 374.CrossRefGoogle ScholarPubMed
18. Kanal, K, Busch-Hallen, J, Cavalli-Sforza, T et al. (2005) Weekly iron–folic acid supplements to prevent anemia among Cambodian women in three settings: process and outcomes of social marketing and community mobilization. Nutr Rev 63, 12 Pt 2, S126S133.CrossRefGoogle ScholarPubMed
19. Nisar, YB, Alam, A, Aurangzeb, B et al. (2014) Perceptions of antenatal iron–folic acid supplements in urban and rural Pakistan: a qualitative study. BMC Pregnancy Childbirth 14, 344.CrossRefGoogle Scholar
20. Pal, PP, Sharma, S, Sarkar, TK et al. (2013) Iron and folic acid consumption by the ante-natal mothers in a rural area of India in 2010. Int J Prev Med 4, 12131216.Google Scholar
21. Seck, BC & Jackson, RT (2008) Determinants of compliance with iron supplementation among pregnant women in Senegal. Public Health Nutr 11, 596605.CrossRefGoogle ScholarPubMed
22. Srivastava, RK, Kotecha, PV, Singh, V et al. (2015) Community based intervention (CBI) for demand generation of IFA consumption among rural pregnant women. Int J Recent Sci Res 6, 50235026.Google Scholar
23. Yekta, Z, Ayatollahi, H, Pourali, R et al. (2008) Predicting factors in iron supplement intake among pregnant women in urban care setting. J Res Health Sci 8, 3945.Google ScholarPubMed
24. Khan, NC, Thanh, HT, Berger, J et al. (2005) Community mobilization and social marketing to promote weekly iron–folic acid supplementation: a new approach toward controlling anemia among women of reproductive age in Vietnam. Nutr Rev 63, 12 Pt 2, S87S94.CrossRefGoogle ScholarPubMed
25. Aguayo, VM, Koné, D, Bamba, SI et al. (2005) Acceptability of multiple micronutrient supplements by pregnant and lactating women in Mali. Public Health Nutr 8, 3337.CrossRefGoogle ScholarPubMed
26. Nisar, YB, Dibley, MJ & Mir, AM (2014) Factors associated with non-use of antenatal iron and folic acid supplements among Pakistani women: a cross-sectional household survey. BMC Pregnancy Childbirth 14, 305.CrossRefGoogle ScholarPubMed
27. Wendt, A, Stephenson, R, Young, M et al. (2015) Individual and facility-level determinants of iron and folic acid receipt and adequate consumption among pregnant women in rural Bihar, India. PLoS One 10, e0120404.CrossRefGoogle ScholarPubMed
28. Lutsey, PL, Dawe, D, Villate, E et al. (2008) Iron supplementation compliance among pregnant women in Bicol, Philippines. Public Health Nutr 11, 7682.CrossRefGoogle ScholarPubMed
29. Young, S, Ali, SM, Beckham, S et al. (2009) The potential role of private pharmacies in maternal iron supplementation in rural Tanzania. Food Nutr Bull 30, 1623.CrossRefGoogle ScholarPubMed
30. Angeles-Agdeppa, I, Paulino, LS, Ramos, AC et al. (2005) Government–industry partnership in weekly iron–folic acid supplementation for women of reproductive age in the Philippines: impact on iron status. Nutr Rev 63, 12 Pt 2, S116S125.CrossRefGoogle ScholarPubMed
31. Dickerson, T, Crookston, B, Simonsen, SE et al. (2010) Pregnancy and village outreach Tibet: a descriptive report of a community- and home-based maternal–newborn outreach program in rural Tibet. J Perinat Neonatal Nurs 24, 113127.CrossRefGoogle ScholarPubMed
32. Ndiaye, M, Siekmans, K, Haddad, S et al. (2009) Impact of a positive deviance approach to improve the effectiveness of an iron-supplementation program to control nutritional anemia among rural Senegalese pregnant women. Food Nutr Bull 30, 128136.CrossRefGoogle ScholarPubMed
33. Pandey, S, Maharjan, MR, Thapa, M et al. (n.d.) Community-Based Integrated Interventions Improve Coverage of and Compliance with Iron Supplementation in Nepali Women. Ottawa: Micronutrient Initiative.Google Scholar
34. Bharti, S (2004) Feasibility of ‘directly observed home-based twice-daily iron therapy’ (DOHBIT) for management of anemia in rural patients: a pilot study. Indian J Med Sci 58, 431438.Google ScholarPubMed
35. Bhutta, ZA, Rizvi, A, Raza, F et al. (2009) A comparative evaluation of multiple micronutrient and iron–folic acid supplementation during pregnancy in Pakistan: impact on pregnancy outcomes. Food Nutr Bull 30, 4 Suppl., S496S505.CrossRefGoogle ScholarPubMed
36. Phuc, TQ, Mihrshahi, S, Casey, GJ et al. (2009) Lessons learned from implementation of a demonstration program to reduce the burden of anemia and hookworm in women in Yen Bai Province, Viet Nam. BMC Public Health 9, 266.CrossRefGoogle ScholarPubMed
37. Shivalli, S, Srivastava, RK & Singh, GP (2015) Trials of improved practices (TIPs) to enhance the dietary and iron–folate intake during pregnancy – a quasi-experimental study among rural pregnant women of Varanasi, India. PLoS One 10, e0137735.CrossRefGoogle ScholarPubMed
38. Garcia, J, Datol-Barrett, E & Dizon, M (2005) Industry experience in promoting weekly iron–folic acid supplementation in the Philippines. Nutr Rev 63, 12 Pt 2, S146S151.CrossRefGoogle ScholarPubMed
39. Mora, JO (2007) Integrated Anemia Control Strategy Has Significantly Reduced Anemia in Women and Children in Nicaragua. Ottawa: Micronutrient Initiative.Google Scholar
40. Casey, GJ, Phuc, TQ, Macgregor, L et al. (2009) A free weekly iron–folic acid supplementation and regular deworming program is associated with improved hemoglobin and iron status indicators in Vietnamese women. BMC Public Health 9, 261.CrossRefGoogle ScholarPubMed
41. Emamghorashi, F & Heidari, T (2004) Iron status of babies born to iron-deficient anaemic mothers in an Iranian hospital. East Mediterr Health J 10, 808814.CrossRefGoogle Scholar
42. Seck, BC & Jackson, RT (2009) Providing iron/folic acid tablets free of charge improves compliance in pregnant women in Senegal. Trans R Soc Trop Med Hyg 103, 485492.CrossRefGoogle ScholarPubMed
43. Ugwu, EO, Olibe, AO, Obi, SN et al. (2014) Determinants of compliance to iron supplementation among pregnant women in Enugu, Southeastern Nigeria. Niger J Clin Pract 17, 608612.CrossRefGoogle ScholarPubMed
44. Galloway, R, Dusch, E, Elder, L et al. (2002) Women’s perceptions of iron deficiency and anemia prevention and control in eight developing countries. Soc Sci Med 55, 529544.CrossRefGoogle ScholarPubMed
45. Maternal and Child Integrated Program (2011) Community-Based Distribution for Routine Iron/Folic Acid Supplementation in Pregnancy. Washington, DC: USAID.Google Scholar
Figure 0

Table 1 Summary of key findings from articles included in the present review of community-based distribution of iron–folic acid supplementation in low- and middle-income countries