Profile of study participants
Forty seven rural and 26 urban mothers participated in 6 and 4 FGDs respectively. The IDIs were conducted with six rural and 4 urban currently pregnant women. The basic characteristics of all women, who participated in the study from the rural and urban communities, are shown in Table 1. The IDIs were conducted with the six LHWs working in the Swabi district and with the four doctors working at the PIMS Maternal and Child Health Centre, Islamabad.
Perception of IFA supplements
The majority of the participating women were aware of antenatal IFA supplementation. The rural women knew the supplements by names such as ‘tablets to provide strength’ or ‘red tablets’. The rural women had limited information about the IFA supplements and their benefits. A few of the rural women reported about the supplements as providing strength to their weak bodies during the pregnancy; curing dizziness, lethargy and the back pain; improving maternal health and wellbeing; needing to be taken once daily and continued throughout the pregnancy; and to prevent complications during the pregnancy and at the time of delivery.
“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”
(A rural mother of three children who participated in FGD).
“It prevents the complications during the pregnancy and at the time of delivery”
(A currently pregnant rural woman who participated in IDI).
The urban women, on the other hand, were aware of the various brand names of the supplements available in the market. A substantial majority of the urban women were able to describe the supplements and reported the benefits of the supplements as improving the haemoglobin level; improving the appetite; curing anaemia; needing to be taken once daily and continued throughout pregnancy; improving maternal health and the health and growth of the foetus/baby; preventing delivery complications; and taking a good diet (such as vegetables and meat) along with the supplements.
“These [supplements] are good to take during the pregnancy because these improve the haemoglobin levels and improve the health of mother and health and growth of the baby inside the mother’s womb”
(A currently pregnant urban woman who participated in an IDI).
Nevertheless, some of the selected women were not aware of the antenatal IFA supplements. They had no information about the supplementation program and the benefits of the supplements. They reported several reasons for their lack of awareness and the common reasons included: no visits by the LHW because they lived some distance away; no visits by them to any health facility during pregnancy; poverty and no education; and no information given to them by the doctors even when they visited a health facility.
“We live on the other side of the village and she [LHW] doesn’t come to our house; we are very poor and it is difficult for us to go to a hospital”
(A pregnant rural woman who participated in an IDI).
All the participating LHWs and the doctors were aware of the IFA supplements and their health benefits. LHWs reported that the women in their communities knew about the supplements and called these supplements as ‘tablets to provide the strength’, ‘red tablets’ or ‘blood producing tablets’.
“These tablets are good for the health of pregnant women because they face many hardships during their pregnancy; they feel weakness and dizziness; these tablets cure them and provide them strength; here [village] women know about these tablets as to provide strength, while some of them call them as tablets to produce blood”
(A LHW working for the last 7 years who participated in an IDI).
The doctors reported that the majority of the pregnant women who visited the health facility knew about the supplements and that a few of them even knew the brand names available in the market.
Source of information about antenatal IFA supplements
The great majority of the rural women reported receiving information about IFA supplementation from the LHWs, and a few of them also reported receiving information from doctors when they visited health facilities. The urban women received the information about the supplementation from a variety of sources. Most of them received information from doctors, but some of them also received information from their family members, friends, neighbours, televisions or from newspapers/magazines.
Sources of antenatal IFA supplements
The major sources of the antenatal IFA supplements stated by the women were LHWs (rural women); government health facilities; and private clinics or pharmacies. The majority of rural women reported that when they visited healthcare providers for problems related to their pregnancy they received or were prescribed IFA supplements. The common problems for which they sought care included back pain, feeling weak, dizzy and lethargy. A few of them also visited the healthcare providers for routine ANC services and also received IFA supplements.
“I was not feeling well few months ago, as I had severe back pain and feeling weak; my mother took me to a private clinic and the doctor over there prescribed me these tablets along with some other medicines”
(A rural woman pregnant for the first time who participated in an IDI).
Among the urban women, some of them went to the health facility for the routine ANC services and received or were prescribed supplements; while others visited a health facility due to some problems related to their pregnancy and received the supplements. Occasionally, a family member also advised urban pregnant women to use these supplements.
“I was admitted to the hospital because I had some internal problems with bleeding during my previous pregnancy; the senior doctor prescribed me these tablets at the time of discharge”
(An urban mother of three children who participated in a FGD).
Reasons to use antenatal IFA supplements - facilitating factors
The women reported several reasons for using IFA supplements during pregnancy including: they had knowledge of the benefits of the supplements; they had trust in the healthcare providers; the supplements were available and they had the financial capacity to buy them; they felt better after taking the supplements; and they received support from family members to take the supplements.
“I know these tablets are good to provide strength to body which is weak during pregnancy, and also improve dizziness; these tablets are good for my health”
(A rural mother of three children who participated in a FGD).
“When I was pregnant my sister-in-law advised me to take these tablets because these tablets have advantages for myself and for the health of my child; afterward, doctor in this hospital also told me about them”
(An urban woman pregnant for the first time who participated in an IDI).
LHWs reported that they provided the supplements to all the pregnant women because they were a part of the routine care during the pregnancy; to improve the health of the pregnant women; and to cure anaemia or low haemoglobin levels during the pregnancy.
“When I visit them [pregnant women] for check up during their pregnancy, I provide them these tablets; sometime pregnant women have some health problems like weakness, dizziness, so I provide them these tablets and they feel better afterwards” (A LHW working for 4 years who participated in an IDI).
The doctors also stated various reasons to prescribe the supplements to all the pregnant women visiting them, including that they are a part of routine ANC services; due to poor dietary habits of the pregnant women; due to signs or symptoms of anaemia, or low measured haemoglobin levels; and to improve maternal health and growth and the development of the newborn.
Timing of the start of antenatal IFA supplements
A substantial majority of the women started the antenatal IFA supplementation during the second trimester of their pregnancy. LHWs reported distributing the IFA supplements to all the pregnant women in their catchment area from the 4th or 5th month of their pregnancy onwards. While doctors also reported that they prescribed IFA supplements during the second trimester of pregnancy to the pregnant women who visited the hospital, either for routine check-ups or with some specific problems.
Barriers to antenatal IFA supplementation
The common barriers to the use of IFA supplements reported by the urban and rural women included forgetting to take them on a daily basis; the non-availability of the supplements; their limited financial capacity to buy them; no ANC services available; family members such as mother-in-law, husband or mother did not allow them to use the supplements; they did not know about the benefits and they had no education; they were afraid of the supplements or they had experienced side effects (like vomiting, nausea or constipation); and they considered them to be like contraceptives. In addition, the urban women also reported that they felt better and stopped the IFA supplementation after few days without consultation with their healthcare providers.
“I stopped these after few days because I forgot to take on each day as I have many duties to perform at home and difficult to remember on each day”
(A rural mother of three children who participated in a FGD).
“I used these tablets but after few days I had vomiting and diarrhoea with these and my mother-in-law told me to stop this medicine; she [mother-in-law] told me not to take any medicine during pregnancy”
(An urban currently pregnant woman who participated in an IDI).
According to healthcare providers the common barriers to the use of IFA supplements were: the women forgot to take them daily; family members mainly mother-in-law and husband did not allow the women to use them; the woman felt better and stopped without consultation; the women did not take medicines during the pregnancy; the supplements were not available or the woman had limited financial capacity to buy them; the woman did not visit healthcare providers; fear of the supplements or previous experience of the side effects of the supplements; the women did not know the advantages of these supplements; and the women had no education.
“There are some women in my village who do not follow our advice because their family [husbands or mothers-in-law] don’t allow them; as they think it is bad to take medicines during pregnancy because medicines have some negative effects on baby’s health”
(A LHW working for 12 years who participated in an IDI).
The majority of the women were of the view that they would like to use the supplements in the future. However, some of them wanted to receive the supplements in an adequate quantity and free of charge throughout the pregnancy. They also wanted to recommend the supplements to other pregnant women in their family or neighbourhood. A few of them, who had experienced some side effects or were not aware of the benefits associated with the supplements, did not want to recommend the supplements to other pregnant women.
Pathways of procurement of antenatal IFA supplements by a pregnant woman
Figure 2 summarizes the women’s and the healthcare providers’ perceptions of the process of procurement of antenatal IFA supplements by a pregnant woman. When a woman becomes pregnant, she is likely to discuss her pregnancy and what she needs to do with her family members, such as mother-in-law, husband, mother or sisters-in-law. Often, a family member will take her to the health facility (government/private) or LHW (in the rural communities), for routine check-ups or for a health problem. If the woman visits a LHW, the IFA supplements when available are provided free of charge, but if the LHW does not have a supply, the woman will be referred to a government health facility. If she visits a government health facility, she will either receive the IFA supplements free of charge, or if the supplements are not available at the government health facility, the doctor will prescribe them for her. Similarly, if she visits a private clinic, the healthcare provider prescribes her the supplements. Once she gets the prescription, sometimes she will purchase the supplements from a pharmacy. A pregnant woman will not use IFA supplements during her pregnancy if she does not receive any ANC services, or if her family members (mother-in-law, husband, mother) do not allow her to use them, or if she avoids taking medicines during pregnancy, or if she is not aware of IFA supplements and their benefits, or if she has limited financial capacity to purchase the supplements.
Pathways of consumption of antenatal IFA supplements by a pregnant woman
Figure 3 summarizes the pathways of perceptions of the women and the healthcare providers about the consumption of IFA supplements by a pregnant woman. Once a pregnant woman receives the supplements, sometimes she discusses their use with a family member mainly with her mother-in-law, husband, and mother or occasionally with her sisters-in-law, who may or may not allow her to take them. She may continue taking the supplements regularly if she perceives the benefits of the supplements, or if she trusts her healthcare provider, or if the supplements are available, or if she has the financial capacity to purchase them, or if her family members support her taking them, or if she feels an improvement in her health. She may not take IFA supplements at all or she may stop the supplements after using them for few days or weeks if she forgets to take them each day, or if she is not aware of the need to continue taking them throughout her pregnancy, or if she feels better and stops without consulting her healthcare provider, or if she is not aware of the advantages of the supplements, or if she is not able to obtain a continuing supply of the supplements (non-availability), or if she has limited financial capacity to buy them, or if she experiences some side effects.