The Paternal Education Paradox: Socioeconomic Determinants and Male Involvement in Antenatal Iron-Folic Acid Adherence in Bosaso, Somalia

<ns5:p>Background Adherence to iron–folic acid (IFA) supplementation during pregnancy is essential for preventing maternal anemia and improving pregnancy outcomes. However, adherence remains suboptimal in many low-resource settings. Evidence on the role of paternal education, socioeconomic determinants, and male involvement in IFA adherence remains limited in Puntland State, Somalia. This study assessed factors associated with IFA supplementation adherence among pregnant women attending antenatal care services in Bosaso. Methods A facility-based cross-sectional study was conducted from January to March 2026 among 400 pregnant women attending selected antenatal care facilities in Bosaso, Puntland State, Somalia. Data were collected using a structured interviewer-administered questionnaire. The original dataset was prepared in SPSS format and subsequently analyzed using Stata version 16. Adherence was defined as taking IFA tablets on at least four days per week during the previous month. Descriptive statistics, Pearson’s chi-square test, and bivariable and multivariable logistic regression analyses were performed. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported, and statistical significance was declared at p < 0.05. Results Overall, 198 (49.5%) participants had high adherence to IFA supplementation, while 202 (50.5%) had low adherence. Partner’s education, maternal education, maternal occupation, partner’s occupation, and household size were significantly associated with adherence in chi-square analysis. In multivariable analysis, adherence was independently associated with age, marital status, maternal occupation, partner’s occupation, gestational age, timing of ANC initiation, number of ANC visits, anemia-related knowledge, and IFA prescription status. Women who were not prescribed IFA supplements had lower odds of adherence than those who were prescribed IFA supplements. Conclusion IFA adherence among pregnant women in Bosaso was suboptimal. The findings suggest that adherence is shaped by individual, household, partner-related, and health-service factors. Strengthening ANC counseling, ensuring consistent IFA prescription, and promoting family-centered maternal nutrition interventions may improve adherence.</ns5:p>