Concern over low uptake of iron, folic acids by expectant women

It is 8.30am on a Tuesday and tens of patients are streaming in at the Jaramogi Oginga Odinga Teaching and Referral Hospital (JOORTH) in Kisumu.

A number of nursing and expectant women have already formed queues waiting for their turn to see a health expert at the maternal child health section.

Ms Nancy Atieno is among those in the queue for her second antenatal care clinic. “My first visit was three months ago after missing my periods. I took a pregnancy test which came back positive.”

She explains that today she will be checking her weight and undergo an abdominal examination while the health workers will also be looking out for any pregnancy danger signs.

Once she is done, the health officer will take her through a short session on important nutrients required for foetal growth and development before handing her a packet of iron and folic acid supplement (Ifas).

The idea of taking the supplements is new to Nancy, who says she did not use them when expecting her first child 10 years ago. “My first pregnancy was smooth; however, I ended up losing a lot of blood during delivery and had to seek blood transfusion services,” she explains.

The single tablet, which contains iron and folate supplements, is meant to build the blood supply in the body of an expectant mother to prevent cases of anaemia. The condition often results in severe morbidity and may lead to death if not attended to early enough.

Anaemia is characterised by lack of healthy red blood cells. It affects 32 million pregnant women worldwide and up to half of all pregnant women in low and middle income countries.

During foetal growth and development, a woman’s blood supply may drop to acute levels, leading to hospitalisation, death of the mother or the unborn baby, or of both.

To protect herself and her unborn baby, Ms Anne Awino has been visiting the Homa Bay County Teaching and Referral Hospital for her monthly Ifas supply.

“After work every evening, I am always  weak. At times I have headaches,” says Anne, adding that her energy levels always improve after taking her dose.

Anne says her major challenge with taking the pills is adherence; at times, she forgets to take the pill until she starts feeling sickly.

In an effort to prevent maternal deaths due to anaemia, Kenya adopted the use of oral iron and folic acid supplements for pregnant women in 2010.

The latest Kenya Demographic Health Survey revealed that the uptake of the supplements is still low. The proportion of women taking the supplements for 90 days during pregnancy is at eight per cent while those taking deworming medication is 17 per cent.

Kenya has, however, recorded a slight improvement in maternal child health with a reduction of untimely deaths, thanks to Ifas, among other interventions. In 2020, outgoing Chief Administrative Secretary in the Ministry of Health, Dr Mercy Mwangangi, said Kenya had reduced maternal mortality rates from 488 to 362 per 100,000 live births while the antenatal visits had also increased from 92 to 96 per cent over the decade.

“Child mortality has also declined by over 20 per cent since 2008,” she said.

Ms Betty Okundi, the principal nutritionist at JOOTRH, says although the country has made major improvements, there is still a lot more to be done to ensure a constant supply and uptake of the supplement.  “Our preconception clinics are still low yet a woman needs to start taking the supplements at least three months before conception or within the first 28 days of gestation,” says Betty.

She explains that taking the pills before conception or within the first month of conception protects the baby from neural tube defects including spina bifida.

At JOOTRH, she says, the pre-conception clinics are still struggling at less than 30 per cent while in Homa Bay, the County Director Preventive and Promotive Health, Prof Adel Ottoman, says only a handful visit facilities for the services.

Women with lower blood levels are also encouraged to take the pill for six weeks after giving birth.

Ms Margaret Kwaya, a nurse at Homa Bay Teaching and Referral Hospital, says that while pregnant women can get the nutrients in meals, most of them always avoid some particular foods that may deny them the nutrients necessary for the entire nine-month period.

The supplements, when taken alongside a balanced diet, will see the woman build up her nutrient stores.

JOOTRH Maternal Child Health Nurse In-Charge Olivia Magomere says at least 100 pregnant women visit the facility on a daily basis and are offered Ifas regardless of their haemoglobin levels.

The supplementation is done alongside controlling malaria infections and deworming, which often lead to a reduction in blood levels.

Major challenge

Olivia says the introduction of supplements has greatly reduced cases of anaemia during pregnancy at the largest referral facility in western Kenya.

“Our major challenge is the defaulters,” says Olivia,  underlining the need to enhance awareness and male involvement.

The nurse says health workers have made it a habit of checking the blood levels of the women during the ANC visits.

Dr Mary Kamau, a lecturer at the University of Nairobi’s Nursing Department, says involving community health volunteers (CHVs) in the distribution of the supplements will go a long way in ensuring compliance.

In her 2018 study on iron and folic acid supplementation in Kiambu County, Dr Kamau established that a number of women would end up missing the dosage due to irregular supply in health facilities. “We are advocating for the consideration of a community based approach of Ifas, using CHVs to supply the supplements,” says Dr Kamau.

She says health facilities should enforce use of available policy guidelines while the country should carry out additional research on the same in order to bridge the existing gaps.

In Homa Bay, Prof Ottoman says, maternal mortality is at 583 per 100,000.

“Although we have not conducted another survey since 2014, we can gladly confirm that the number of cases of anaemia and birth defects have greatly reduced,” he says.

He says one of the challenges medical professionals are facing is occasional stock outs, which have been reported in both Homa Bay and Kisumu counties. A spot-check by Healthy Nation revealed empty stores. Prof Ottoman has called on counties to increase the budgetary allocations on Ifas in order to improve the procurement of these supplements.

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