Understanding Patterns of Receipt and Consumption of IFA Supplements During Pregnancy: Empirical Considerations for Measuring Coverage

Objectives: Daily iron-folic acid (IFA) supplementation during pregnancy is a core intervention in low- and middle-income countries. Yet, there is a concern of poor validity and biased population coverage estimates using maternal reports of total number of IFA supplements. This study examined patterns of IFA receipt and consumption among pregnant women in India and identified considerations for measuring coverage of IFA supplementation. Methods: Data were from a cohort study of pregnant women nested in the cluster-randomized control trial of maternal nutrition interventions provided during antenatal care in two districts of Uttar Pradesh, India in 2019. Pregnant women were recruited and followed up to 7 times: early pregnancy (< 4 months, n=475), monthly between early and late pregnancy (3-4 times), late pregnancy (≥7 months, n=373) and post-partum (42 days after birth, n=399). Descriptive analyses were used to report various elements of IFA supplements including receipt or buy, formulation, dosage, provider, quantity received and consumed, how to estimate quantity, and recall period. Results: About 33% of women in early pregnancy and 94% in late pregnancy received any IFA tablets, mostly for free. Additionally, 16% purchased at least one time across pregnancy, most were of syrup/liquid form. There was no association between respondent characteristics (age, education, caste, number of antenatal visits, and wealth) and free/purchased IFA. Throughout pregnancy, women received of a total of 98 tablets and consumed 67 tablets, and only 19% consumed 90+IFA tablets. 63-87% women estimated IFA by counting available tablets/strips during pregnancy, but most of them relied on recall during postpartum. The correlation between IFA received and consumption was weak to moderate and higher in late than early pregnancy (correlation coefficient 0.46 vs. 0.25, respectively). Higher IFA consumption was associated with higher number of ANC visits, but there was no association with other factors. Less than 1% of women inconsistently reported number of IFA received across rounds, and 2-13% reported a higher number of IFA consumed than received. Conclusions: How IFA supplements are received and consumed by women varies throughout their pregnancy which need to be taken into consideration for coverage measurement. Funding Sources: Bill & Melinda Gates Foundation, through DataDENT.