Infections, vitamin A, B12, and riboflavin deficiencies as well as blood disorders are the causes for anemia [
Deficiencies in iron and folic acid during pregnancy can negatively impact the health of the mother, her pregnancy, as well as fetal development [
The proportion of iron deficiency anemia (IDA) is varied based on age, sex, and region [
The World Health Organization recommended that 80% of communities in all countries should receive the standard dose of iron folic acid. But, from all targeted countries, only Nepal and Senegal have reached greater than 50% for IFA supplementation during pregnancy [
The burden of IDA during pregnancy is not only reduced by initiating of drugs, but also it is highly prevented and controlled by the compliance with IFA supplementation. Compliance, in this case, is defined as taking IFA tablets for 90 days and above [
In Ethiopian context, different studies have been conducted to determine the prevalence of compliance with IFA supplementation and associated factors [
Different studies also revealed that socio-demographic, maternal, and health service related factors were the main determinants of compliance to IFA supplementation. Among the sociodemographic factors of women like age [
As mentioned above, varieties of studies were conducted to estimate the prevalence of IFA compliance in Ethiopia. However, prevalence of IFA compliance ranges from 3.5% [
The results of this review were reported based on the Preferred Reporting Items for Systematic Review and Meta-Analysis statement (PRISMA) guideline [
All cross-sectional studies were included in the current review. Those studies which had reported the prevalence of IFA compliance and published in English were considered. There was no restriction of the study period. All articles which were available in the search sources from October 29, 2018 to November 29, 2018 were included. Citations without abstract and/or full-text, anonymous reports, editorials, and qualitative studies were excluded from the analysis.
PubMed, Web of Science, Cochrane library, and Google Scholar were accessed. Articles with incomplete reported data were handled through contacting corresponding authors.
The core search terms and phrases were “prevalence”, “adherence”, “compliance”, “iron”, “folic acid”, “supplementation”, “utilization”, “uptake”, “number of ANC visit”, and “Ethiopia” were the main key searching terms used to search from October 29, 2018 to November 29, 2018. “OR” or “AND” were used separately and in combination as Boolean operators.
Retrieved studies were exported to reference manager software, Endnote version 7 to remove duplicate studies. Three independent reviewers screened the title and abstract. The disagreement was handled based on established article selection criteria. Three independent authors conducted the abstract and full-text review.
Regarding associated factors, we selected the number of ANC visits to see its effect on the compliance to iron-folic acid supplementation. We selected this factor because of the following reasons: firstly, this factor was the most important factor, which ultimately influence the compliance to iron-folic acid supplementation. Secondly, the effect of the number of ANC visits on compliance to iron-folic acid supplementation has been reported in variable strength of association from different studies [
A standardized data extraction format, which was adopted from the Joanna Briggs Institute (JBI) data extraction format [
The outcomes variables of this systematic review are: (a) compliance to IFA supplementation (the primary outcome), which is defined as taking of 90 days and above provided iron-folic acid tablets [
The quality of each cross-sectional study was assessed by using The Newcastle-Ottawa Scale [
Publication bias was checked by funnel plot and more objectively through Begg’s and Egger’s regression test [
The search strategy retrieved 590 articles from PubMed, Cochrane library, Web of Science, Google Scholar, and other sources. After duplication was removed, 99 articles remained of which 78 were excluded as a result of not fulfilling to our inclusion criteria by reviewing for their titles and abstracts. Then 21 full-text articles were accessed based on inclusion criteria [
Flowchart to a selection of studies for a systematic review and meta-analysis of the prevalence of compliance to iron-folic acid supplementation and its association with a number of ANC visit in Ethiopia, 2018.
The eligible twelve studies were published from 2014 to 2018. The total sample size in the current review was 6229. All studies were conducted by using cross-sectional study design. Three of the studies were from the Tigray region [
Descriptive summary of 12 studies included in the meta-analysis of prevalence compliance to iron-folic acid supplementation in Ethiopia, 2018.
Region | Study site | Author name | Publication year | Sample size | Response rate | Prevalence | Newcastle-Ottawa Scale |
---|---|---|---|---|---|---|---|
Tigray | Community | Gebre et al. | 2015 | 714 | 100 | 35.85 | 7 |
Community | Getachew et al. | 2015 | 320 | 100 | 64.70 | 7 | |
Facility | Gebre et al. | 2015 | 450 | 98.4 | 22.90 | 7 | |
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Amhara | Community | Taye et al. | 2015 | 628 | 100 | 20.40 | 8 |
Facility | Birhanu et al. | 2018 | 418 | 100 | 55.30 | 7 | |
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Oromia | Facility | Tegegne et al. | 2017 | 405 | 95.9 | 18.00 | 8 |
Facility | Niguse et al. | 2018 | 296 | 93.00 | 59.80 | 7 | |
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Southern | Facility | Jikamo et al. | 2018 | 365 | 86.60 | 69.59 | 6 |
Community | Gebremedhin et al. | 2014 | 1563 | 97.10 | 3.50 | 6 | |
Community | Arega et al. | 2015 | 296 | 97.60 | 39.20 | 7 | |
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City administration | Facility | Gebreamlak et al. | 2017 | 557 | 88.90 | 60.00 | 8 |
Facility | Aabdi et al. | 2018 | 217 | 97.30 | 76.00 | 6 |
The Newcastle-Ottawa Scale quality appraisal criteria established for cross-sectional was used. The studies included in this systematic review and meta-analysis had no considerable risk. Therefore, all the studies were considered [
The estimated overall prevalence of compliance to IFA is presented in a forest plot (Figure
Subgroup prevalence of compliance to iron-folic acid supplementation Ethiopia, 2018 (
As a result of sever heterogeneity; we performed subgroup analysis based on the geographical setting. Accordingly, the highest prevalence was observed in the city administration (Addis Ababa and Dra Dawa) with prevalence of 67.94% (95% CI: 52.28, 83.62) and the lowest prevalence was observed in southern Ethiopia with prevalence of 37.28% (95% CI: −2.90, 77.47) (Figure
A random effect model was employed to estimate the pooled prevalence of compliance with iron-folic acid supplementation. Different factors associated with the heterogeneity such as publication date, sample size and study site were investigated using univariate meta-regression models. From these variables, none of them were statistically significant (Table
Related factors with heterogeneity of compliance with iron-folic acid supplementation in the Current meta-analysis 2018 (
Variables | Coefficient |
|
---|---|---|
Publication years | 2.845 | 0.774 |
Sample size | −0.018 | 0.388 |
Study site at community | −9.50 | 0.363 |
A funnel plot showed asymmetrical distribution (Figure
Funnel plot for publication bias, Logprop Or Lnp (Log of Proportion) represented in the X-axis and standard error of log proportion in the Y-axis.
Among all twelve reviewed studies in the current analysis, the study conducted by Gebremedhin et al. [
The sensitivity analysis showed the pooled prevalence when the studies omitted step by step.
A total of four studies which examined the association between the number of ANC visit and compliance with IFA supplementation were included in the pooled analysis of AOR. Hence, the result in this review indicated the odds of having four or more ANC visits, increases the women compliance to IFA supplementation [OR 2.54 (95% CI: 1.43, 4.50)] (Figure
The relationship between the number of ANC visit and compliance with iron-folic acid supplementation in Ethiopia, 2019.
In this study, systematic review and meta-analysis were used to assess the pooled prevalence of women compliance to IFA supplementation and its association with the number of ANC visit. Although the WHO guidelines recommend that all women should take the IFA dose for at least 90 days and above during their pregnancy time [
On the other hand, this finding suggested that the prevalence of compliance with IFA supplementation is much higher than the Ethiopia Demographic and Health survey (EDHS) and other sub Saharan countries [
Based on the subgroup analysis, the prevalence of iron folic acid compliance was high in city administration (Addis Ababa and Dre Dawa) (67.94%) as compared to other regions. Ethiopian demographic and health survey (EDHS) also reported that urban mothers had the high rate of compliance to iron folic acid supplementation as compared to their rural counterparts [
Based on the pooled analysis of four AOR of studies, ANC was significantly associated with compliance of IFA. The odds of having four and more ANC was three times higher to the compliance with IFA supplementations. This finding is similar to other studies conducted with EDHS data from 22 countries [
This study identified ANC visit as an important independent factor for women compliance with IFA supplementation in Ethiopia. National and regional policy and decision makers will have to work on to improve these specific risk factors. Different strategies with appropriate community-based interventions on adherence of ANC visit need to be considered for improving overall compliance of IFA in Ethiopia.
The first limitation of the study was only English articles or reports were considered to carry out this analysis. All studies included in this review were cross-sectional in nature and therefore the outcome variable might be affected by other confounding variables.
Current compliance with IFA supplementation was lower than the world health organization recommendation. Mothers from city administration who utilized antenatal care for four and above times, had high level compliance with iron-folic acid supplementation. Therefore, health care professionals should focus on increasing compliance with IFA supplementation by providing the recommended number of ANC visits.
Ante natal care
Confidence interval
Ethiopia demographic health survey
Iron-folic acid
World health organization.
The authors declare that they have no conflicts of interest.