Iron–folic Acid Compliance: An Overlooked Determinant of Maternal Anemia and Birth Outcome

Sir, The prevalence of anemia among pregnant women as per the National Family Health Survey 5 (2019–2021) is 52.2%.1 We read with great interest the article titled “Change in hemoglobin as compared to absolute hemoglobin as a determinant of birth weight: A secondary data analysis from Eastern India” by Kaur et al.,2 which addressed an important public health concern dynamic hemoglobin trend as a determinant of birth weight. However, we would like to offer some observations and suggestions regarding the findings that could guide future research in this domain. While the authors rightly acknowledged that “the study fails to adjust for iron supplementation in pregnancy, which is a crucial factor influencing anemia outcomes.” But a striking finding from Table 2 Association of birth weight with change in mother’s body weight (in kg) (from her prepregnancy weight) of the article was that those babies having a birth weight <2.5 kg the presence of Anemia among mother’s kept increasing every trimester.2 Refer Figure 1 for the same. Iron folic acid (IFA) tablet consumption during pregnancy is one of the crucial components of India’s Anemia Mukt Bharat Program and a critical determinant of maternal hemoglobin status. Compliance variation with IFA supplementation can alter the hemoglobin levels across trimesters in pregnant women.3 Thus, confounding the findings with birth weight. Inclusion of dosage compliance data would have strengthened and contextualized the observed hemoglobin changes. As researchers and policy makers are committed to reduce maternal anemia, are we adequately capturing the real—world effectiveness and adherence to this intervention?To address this gap, future studies could integrate IFA compliance monitoring using simple and feasible methods like data of pill count as a self-reported adherence in the mother and Child Protection (MCP) cards at individual level. Employing community health workers like Accredited Social Health Activist (ASHA) to follow-up records as proxy indicators of compliance or use digital antenatal care (ANC) tracking tools that record IFA dispensing and consumption at the community level. At policy level, enhanced community—based nutritional education/counselling or SMS reminders or peer support groups to reinforce daily intake habits. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.