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Iron supplementation (receipt and consumption) during pregnancy [message #1857] Fri, 04 April 2014 10:38
twilliam is currently offline  twilliam
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Registered: March 2014
Location: Arlington, VA, USA
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The following recommendation is submitted by the USAID-funded Strengthening Partnerships, Results and Innovations in Nutrition Globally (SPRING) Project; the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) Program, Nutrition Branch, Division of Nutrition, Physical Activity and Obesity (DNPAO), of the Centers for Disease Control (CDC); the Micronutrient Initiative; and the Manoff Group. Please see also attached document with mostly the same information but two tabels included.

RECOMMENDATION: Replace questions 421 and 422 in the Woman's Questionnaire with a set of six questions.
The following recommendations would replace and build on the two current questions related to iron supplementation receipt and consumption during pregnancy in the Woman's Questionnaire:

Q. 421: During this pregnancy, were you given or did you buy any iron tablets or iron syrup?
Q. 422: During the whole pregnancy, for how many days did you take the tablets or syrup?

1. What is the information needed and why?

Iron deficiency and iron deficiency anemia are among the most common serious public health problems in the world. WHO recommends that all pregnant women receive a standard dose of 30-60 mg iron and 400 µg folic acid beginning as soon as possible during gestation. In addition to iron and folic acid (IFA), supplements may be formulated to include other vitamin and minerals (WHO 2012). Ideally women should receive iron-containing supplements not later than the first trimester of pregnancy, which means taking 180 tablets before delivery. Compliance with the ideal minimum of 180 IFA tablets during pregnancy, however, is very low, and progress in improving compliance has been slow. The two questions above have been standard, universal DHS questions for 20 years. Recently, however, in the 2011 Bangladesh Woman's Questionnaire, neither of these questions were asked. We hope this change is not indicative of a more common practice or of a change in the core DHS questionnaire--not only in Bangladesh, but in all DHS countries.

Given the 2013 Lancet Nutrition Series' endorsement of the substitution of maternal iron (alone or as iron-folic acid tablets) supplements for multiple micronutrient supplements. It would be useful to be able to track the implementation of this recommendation.

The following information on the receipt and consumption of iron supplements is needed:

a) In the current, standard questionnaire, it is currently impossible to know where women obtained their multiple micronutrient supplements/iron tablets/syrup.
b) It is currently impossible to identify whether women received multiple micronutrient supplements/iron tablets/syrup free of charge or paid for the tablets/syrup they received
c) No information is collected on the number of tablets a woman received during her previous pregnancy (the DHS collects instead, the number of days tablets/syrup were taken).

Very few countries still use syrup. Where it is used, it should be included (as it is in our proposed questions below). Where it is not, however, it should be excluded.

While most countries public health agencies adopt the WHO recommendation of 180 IFA tablets, a few countries recommend fewer. It would be useful for the DHS final report text to note the official recommended number of IFA tablets or the official policy on multiple micronutrients (if there is one).

2. What questions will elicit this information?

Q. 421 should be revised to:

Q. 421a. During this pregnancy, were you given or did you buy iron tablets, IFA tablets, multiple micronutrients or iron syrup preparations like (this/any of these).

SHOW COMMON TYPES OF PILLS/TABLETS/SYRUPS/MICRONUTRIENT SUPPLEMENTS. ASK ABOUT USE OF EACH TYPE DURING THE MOST RECENT PREGNANCY IN THE PAST 5 YEARS

Iron/IFA tablets ................................................ Yes No Don't know
Iron syrup ......................................................... Yes No Don't know
Multiple micronutrients .................................. Yes No Don't know

Q. 421b. If more than one form was received or purchased: In which form did you receive or purchase the most?
Iron/IFA tablets ............................................................ .......... 1
Iron syrup-like preparation .................................................. 2
Multiple micronutrient ......................................................... 3


Q. 421c. Did you get iron tablets or iron syrup during an antenatal care visit, during another visit to a health facility, at a pharmacy, from a community worker/volunteer or from another source? (Check all that apply)
Antenatal Visit to facility....................... 1
Another Facility Visit ........................... 2
Pharmacy ............................................................ ..................... 3
Community worker/volunteer........................ 4
Other Source ............................................................ ............... 5

Q. 421d. Did you purchase your iron or receive it free of charge?
Purchased (some or all)................................... 1
Received Free of Charge (all of it)............. 2
Don't Know ............................................................ . 8

Q. 421e. During the entire pregnancy, how many iron/IFA tablets, syrup or multiple micronutrient supplements did you receive or purchase? (Including all forms; iron/IFA tablets, syrup and multiple micronutrients):
Number •••
Don't Know ...... 998


Following the above revisions, we recommend that Q. 422 be revised to:

Q422a. During the entire pregnancy, for how many iron/IFA tablets/syrup or multiple micronutrient supplements did you take?

Number •••
Don't Know ...... 998


These proposed questions have never been fielded or validated.

3. How will the resulting information be used?

a) To quantify the specific supplement pregnant women used, and to be able to track the implementation of the new Lancet maternal supplementation recommendation.
b) Distinguishing where women obtain their iron supplements would help to target messages and training.
c) Identifying whether or not women paid for their iron supplements would help to identify whether or not having to purchase iron supplements affects how many they obtain and subsequently consume. Many women take some iron supplements, very few take the WHO recommended minimum of 180. This would help to find out why.
d) The number of iron supplements women receive during her previous pregnancy is important, policy-relevant information that would enable ascertaining whether or not a woman did not take the recommended number of tablets because she did not receive enough to do so. Regarding its presentation in the final report, in some countries 90+ tablets is the highest reported cutoff while in others the 180+ cutoff is used. The number of days iron tablets or iron syrup were taken are provided in the datasets, but since many people only use the reports, it might be best to use the WHO ideal minimum cutoff of 180. The ranges for reporting of number of IFA tablets received and taken could expand to: None, <=45, 45-89, 90-134, 135-179, >=180

Two possible table shells for reporting the results are presented below. If information is collected on iron deficiency, iron deficiency anemia or anemia, it should also be presented in the table to provide an indicator of absolute and relative "need" and to aid in prioritizing activities to improve performance.

NOTE: see accompanying file as the tables do not print properly in the portal.


4. The priority among the suggested additions is: 421a, 421e, 422a, 421c, 421d, 421b.

5. Iron deficiency and iron deficiency anemia are among the most common serious public health problems in the world, and inadequate progress is being made in reducing them. It is our view that these questions should be universally included in DHS questionnaires.


Reference:
WHO. Guideline: Daily iron and folic acid supplementation in pregnant women. Geneva. World Health Organization, 2012.


Tim Williams
Senior Strategic Information Advisor
SPRING Project
Arlington, VA, USA
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