A root cause analysis of sub-optimal uptake and compliance to iron and folic acid supplementation in pregnancy in 7 districts of Zambia

Background Iron and Folic Acid are two of the micronutrients recommended for pregnant women to support optimal maternal outcomes with regard to preventing anaemia and foetal birth defects. It is difficult to establish if women provided with iron and folic acid supplementation in Zambia benefit from it and how well it is implemented. The overall objective of this study was to determine the levels of uptake and compliance to iron and folic acid in pregnancy among women of child-bearing age in Zambia, with a focus on both supply and demand factors. Methods A cross sectional, mixed method study was done. Data was collected in August and September 2015 from six of the 14 districts in which Scaling Up Nutrition interventions were being undertaken as well as Lusaka district. A household survey covering 402 males and females of child-bearing age, 27 key informant interviews amongst key stakeholders and 12 focus group discussions at community level were conducted. Results Antenatal clinic attendance was almost universal (98.7%); the majority of both men (92.1%) and women (97.4%) had heard messages about iron and folic acid supplementation; the majority (96.5%) of women reported having taken iron and folic acid tablets during their last pregnancy, with 61.3% starting in the second trimester, 27.2% during the first trimester, and 7.7% in their third trimester. Eighty-five per cent (80.5%) of the women reported that they had taken all the tablets they were given with about 13.4% not taking all the tablets received. Conclusions Root cause analysis, using both qualitative and quantitative findings, showed that the main challenges faced were long distances to health facilities and high transport costs; some women not being reached with supplementation messaging; lack of formalised and uniform training around delivery of antenatal messages across health care workers; women not attending antenatal monthly to replenish supplements; and forgetfulness to take the drugs daily. While male involvement may be a supportive factor, it sometimes hinders women from accessing antenatal services. Results showed that both uptake and compliance to iron and folic acid supplementation in pregnancy in Zambia were sub-optimal.