Iron is a vital requirement for the synthesis of haemoglobin. Iron deficiency anaemia is a major public health issue worldwide (Kamau et al, 2018; Musyoki et al, 2019). The risk of iron deficiency anaemia is higher in pregnant women, as the demand for physiological iron requirements increases during pregnancy to account for the needs of both the mother and the fetus. The World Health Organization (WHO, 2014) advocates for universal iron supplementation for pregnant women, recommending that they should receive a standard dose of 30–40mg of iron and 400µg of folic acid during pregnancy.
Globally, almost half of all pregnant women are anaemic and the majority of these women live in low- and middle-income countries (Goonewardene et al, 2012; United Nations Children's Fund et al, 2015; Musyoki et al, 2019). In Ghana, the prevalence of iron deficiency anaemia among pregnant women is estimated at 45% (Appiah et al, 2020). To maximise haemoglobin concentration and prevent anaemia during pregnancy, interventions typically include the provision of iron and folic acid supplements to pregnant women (Ghana Statistical Service et al, 2015). The approved dosage in Ghana is 60mg/day of ferrous sulphate and 400μg of folic acid, administered orally once daily for 180 days or more from preconception to birth. This is typically provided in a single combined iron and folic acid tablet (WHO, 2014).
The efficacy and success of policy interventions for preventing anaemia during pregnancy are largely contingent on adherence to the prescribed regimen of iron and folic acid tablets (Peña-Rosas et al, 2015). The use of iron supplements to prevent iron deficiency anaemia in pregnancy is considered one of the most effective ways to prevent anaemia during pregnancy (WHO, 2014). However, several studies have indicated that uptake of iron supplementation in pregnancy is poor in sub-Saharan Africa, leading to adverse pregnancy outcomes, including maternal and neonatal mortality and morbidity, miscarriage, stillbirth, prematurity, low birth weight, pre-eclampsia and low cognitive development of children (Musyoki et al, 2019; Kangalgil et al, 2021; Beressa et al, 2022).
In Ghana, demographic and health survey data from the past 5 years show that less than two-thirds of women (59%) adhered to daily iron tablet consumption for 90 days or more during their most recent pregnancy, and adherence was reportedly higher in urban areas (Ghana Statistical Service et al, 2015). The Tain District annual health report (Fiedler et al, 2014) showed that 90.4%, of pregnant women received iron supplements; however, only 31.2% of mothers reported taking iron tablets for more than 90 days.
Patients' beliefs regarding the origins and significance of an illness, as well as their motivation to adhere to therapy, are closely linked to compliance with healthcare (Vincze et al, 2004; Kamau et al, 2018). Consequently, compliance with a supplementation regimen during pregnancy is partly dependent on women's perceptions of the supplements (Goonewardene et al, 2012; Leila, 2013). Compliance is improved if pregnant women understand that supplements protect against problems during pregnancy and birth (Jahani et al, 2011; Sweileh et al, 2014), while misconceptions can significantly negatively impact compliance. Factors such as concerns about treatment, beliefs about a disease and religious convictions can contribute to noncompliance (Fawzi et al, 2012).
Perceptions and belief are an integral part of medication adherence (Taye et al, 2015; Tefera et al, 2020). Different belief groups may use alternative healing practices and remedies. In New Zealand, a study found that Tongan patients often attributed disease to divine will and viewed it as uncontrollable, leading to a perceived diminished need for medication (Barnes et al, 2004). In Malaysia, certain groups of pregnant women consider long-term use of ‘Western’ medication potentially harmful, and have expressed a stronger trust in herbal or natural remedies (Al-Qazaz et al, 2011).
In Ghana, spirituality significantly influences health practices and healthcare decisions are often guided by spiritual convictions. Common spiritual practices encompass the use of herbal remedies, prayer and seeking advice from a spiritual healer. These beliefs may deter Ghanaians from taking life-saving medication, as they can regard spiritual leaders as superior to medical doctors (Wossilek and Paterson, 2016). Despite education on the benefits of complying with iron nutrition and supplementation, which is offered antenatally by prenatal care providers, many pregnant women still do not comply with iron supplements as a result of their own perceptions of supplementation (Ghana Statistical Service et al, 2015; Appiah et al, 2020).
Understanding pregnant women's beliefs and perceptions of medication can help with the creation of a targeted health education programme for pregnant women, resulting in better adherence to medication and preventing negative health outcomes (Twigg et al, 2016). However, most studies on iron supplementation have focused on compliance, the use of a daily dose compared with a weekly dose and the effectiveness of iron supplements (Kassa et al, 2019). This study explored pregnant women's perceptions and beliefs related to compliance with daily iron supplements in the rural Tain District, Ghana.
Methods
The study used a descriptive qualitative design with an interpretative approach to examine pregnant women's beliefs related to daily intake of iron supplements. This design allowed the investigators to explore, document, and interpret pregnant mothers' beliefs, and how they may support or discourage adherence to daily iron supplements.
Sampling
The participants were pregnant women who received antenatal care in one of 10 health facilities offering maternity care in the Tain District. The inclusion criteria required that pregnant women attended antenatal care and were prescribed iron supplements for a minimum of 1 month. Homogeneous purposive sampling was used to select 20 participants, a non-probability sample selected based on shared characteristics between the participants and the objective of the study. This approach was used to ensure that respondents who were most likely to produce accurate and useful information were selected (Campbell et al, 2020). The participants were identified during antenatal care.
Data collection
Data were collected using a semi-structured interview guide, which facilitated in-depth, face-to-face questioning. The guide was formulated by the authors and centered around beliefs related to compliance with daily iron supplement intake. To ascertain the relevance and appropriateness of the guiding questions, the interview guide was pre-tested with five pregnant women from the Wenchi District health facilities, a region distinct from the main study setting. The Wenchi District was chosen for pre-testing because it shares similar cultural characteristics with the Tain District. Data from the five pretest interviews were excluded from the final data.
Interviews were conducted in Twi, the participants' native language. The authors and research assistants individually approached participants immediately after an antenatal care appointment, discussed the study and gave women an information sheet. Those who consented to participate in the study were asked to schedule a time and date that was convenient to them for the interview. The location, an enclosed office in the study setting, was selected for the participants' convenience.
Each week, the principal author, assisted by two research assistants with expertise in maternal healthcare, conducted five interviews. This schedule allowed for transcription and coding processes, facilitating the identification of response patterns. The research assistants posed probing questions to thoroughly explore the participants' beliefs. The interview process concluded with the 20th participant, as no additional unique information was forthcoming. The interviewers, who neither resided in nor originated from the study district, had no direct influence on the study setting or the participants. Each interview lasted between 20 and 25 minutes and was audio-recorded, with the participants' consent. Throughout the interview sessions, the principal author and the two research assistants made field notes capturing non-verbal cues and other pertinent observations.
Data analysis
The authors and research assistants listened to the recorded interviews for precise transcription and subsequent translation into English. The accuracy and thoroughness of these transcripts were stringently verified by the principal author (field supervisor) and the research assistants prior to English translation.
The first author translated the transcripts, beginning by identifying the subject matter, content, writing style and sections of the text. Key concepts, terminology and any preliminary background reading necessary to understand the transcripts were noted. This was done to establish how key terms would be translated. After a first draft translation was completed, the first author then methodically worked through the translation, comparing the translation with the original text to confirm no content had been missed or misinterpreted, and identify and improve any unnatural or inelegant wording. The translator re-read the translation without reference to the source document, looking solely at quality of expression. Final edits were then carried out to refine the translated text. To ensure fidelity to the participants' perspectives, the translated interviews were rigorously proofread by the second and third authors, who had extensive academic and research acumen in population and health, and midwifery, respectively.
Data analysis followed a thematic approach. A codebook was created, drawing from the interview guides, literature review insights and emerging themes from the data. During coding, each team member read through each transcript and translation multiple times, fostering an in-depth understanding. The generated codes and emerging insights were then collectively deliberated until a group consensus was reached. Following the coding process and code categorisation, an analytic framework was collaboratively established, which was applied across all transcripts to derive the final findings. Data analysis was independently carried out by the first, third, and fourth authors, and their conclusions were independently corroborated by the second author, with the findings further validated by the first and third authors. The culmination of these analyses was the synthesis of codes into comprehensive themes.
Study integrity and reliability
The integrity of the study was reinforced by adhering to the criteria of confirmability, replicability, dependability, and authenticity. Confirmability was bolstered through member checking, which aimed to accurately represent the realities of the participants. This procedure entailed providing five participants with the opportunity to review the data, confirming that their statements were correctly depicted. Additionally, an independent analysis conducted by the first, third, and fourth authors enhanced analytical rigour and corroborated the findings. The trustworthiness of the data was further affirmed through peer debriefing and adherence to the study protocol, which contributed to the study's overall dependability and authenticity.
Ethical considerations
Ethical approval was obtained from the Ethic Committee of Tain District Assembly, Ghana (reference number: TDA/AB/114/236/170). The interview recordings were anonymised and assigned unique identifiers for data protection and tracking purposes. Following transcription, audio files were expunged from the digital recording devices.
Participants were informed that their involvement in the study was voluntary, with the option to withdraw at any point without repercussions. Participants were asked to sign informed consent, and explicitly approved the interview process, audio recording and the publication of the findings. Confidentiality was maintained by conducting the interviews in a private office setting. Participants were assured that all information would be kept strictly confidential. To uphold anonymity, no identifiable personal information was collected.
For minors, assent forms were used (those aged less than 18 years), and the benefits, risks and procedures for the study were read or explained. The participants were given the opportunity to ask questions about the research. Witness for a volunteer was also made to sign against his or her name to confirm that he/she was present while the benefits, risks and procedures of the study were read and explained to the volunteer. All inquires were addressed and the volunteer agreed to participate in the research. No participant withdrew from the study.
Results
The participants' mean age was 28 years old, with a range of 14–42 years. Eight participants had no formal education, five had attended up to primary school, one had obtained a bachelor's degree, two received a diploma and four had secondary education. Five of the participants were Muslim, 12 were Christian and three were Traditionalist. Most of the participants (n=15)were married and five were cohabiting. Five of the participants were nulliparous, 12 were primiparous and three were multiparous. Most of the participants (n=15) were farmers, three were professionals (teachers, nurses), and the remaining two were artisans. Five of the participants were in their first trimester, 10 were in their second trimester and the remaining five were in their third trimester.
There were four main beliefs that negatively affected compliance with daily iron supplementation. It was reported that participants believed they would make the baby ‘too big’, could cause haemorrhage and malformation, could cause nausea and vomiting, and were less effective than herbal medicine.
Iron supplements make the baby ‘too big’
The participants reported the belief that daily iron supplements could cause their babies to become too big to be delivered (fetal macrosomia) and this could lead to either a cervical tear, episiotomy or caesarean section. The participants feared negative repercussions in these situations, such as complications during birth.
‘I was told that if I take iron supplements daily my baby would become too big to deliver. This may lead to a cervical tear, which can cause my death if not managed well’.
PW7
Similarly, one participant felt that if a repair (suturing) for an episiotomy was not performed correctly, it could negatively affect her relationship with her husband.
‘My friend told me that if I take iron supplements daily, I cannot deliver through the vagina, unless the midwife or the doctor performs an episiotomy…since daily uptake of iron supplementation makes the baby too big to be delivered. If the repair of the episiotomy is not done well, it can negatively affect the love my husband has for me’.
PW18
Iron supplements cause haemorrhage and malformation
Three-quarters of the participants were aware that daily uptake of iron supplements improves haemoglobin level. However, they believed that this increase caused harm and would lead to excessive bleeding during birth and fetal malformation.
‘In two of my pregnancies, I took my iron medication as prescribed yet I bled heavily during delivery. I suspect it was as a result of my high blood level due to daily uptake of iron supplement. This time round, I will take iron supplement but not daily as prescribed by the midwife. I want to compare my delivery of this current pregnancy to the previous ones’.
PW09
‘During my second pregnancy, I took my iron supplement daily as directed by [the] midwife. Yet after delivery, my baby was not fine and was admitted into [the] neonatal intensive care unit for two weeks. I believed it was as a result of high haemoglobin due to my compliance with daily uptake of iron supplement’.
PW12
‘During my first and second pregnancies, I only visited antenatal clinic once, yet I delivered peacefully without any complication. But during my third pregnancy, I visited antenatal clinic at the initial stage of my pregnancy and midwife told me my haemoglobin was low so I needed to take my iron supplement serious by taking it daily. I did so; I took my iron supplement daily without missing a day. Unfortunately, during delivery, I bled to the extent that they had to rush me to bigger hospital. I nearly lost my life. Finally, I delivered but my baby had problem with one of his eyes. I believed that this incident was as a result of my compliance with daily uptake of iron supplement which increase my blood [sic]. This current pregnancy, I have decided not to take iron supplement daily’.
PW17
Iron supplements cause nausea and vomiting
Some participants were not aware that nausea and vomiting are common symptoms associated with normal pregnancies, especially during the early stage. They attributed these symptoms to daily uptake of iron supplements, making them reluctant to comply with the daily regimen.
‘My pregnancy is less than 2 months. I try to take my iron supplement daily but anytime I take iron supplement I feel nausea and vomiting. I believe it is due to my uptake of iron supplement. Although, I am told it is a sign of pregnancy and that it will stop after first trimester I still do not believe it’.
PW07
‘I believe iron supplement cause nausea and vomiting. This is my first pregnancy and I started antenatal clinic 2 months ago. Anytime I take my drug I feel nausea and sometimes I vomit. After vomiting, I become weak and dizzy. In view of this, I do not take my pills daily as prescribed’.
PW11
Herbal medicine is more effective
Based on their experiences with both herbal medicine and daily iron supplements, the participants believed that herbal medicine reduced pain and facilitated a quicker labour and birth. They also believed that daily iron supplements prolonged pain and labour.
‘In this community, almost every house you enter you will see a pot of concoction on the fire. This is what we take before going to work’.
PW02
‘I was in a village with my husband when I became pregnant for the first time. I did not go for antenatal clinic because the clinic was far and my husband did not have money. I used herbal medicine prepared by my mother in-law, yet my delivery was smooth and peaceful. I delivered shortly; I realised that I was in labour with the help of traditional birth attendant without experiencing any prolonged pain. However, the situation changed when I became pregnant second time. I started attending antenatal visits because this time, I and my husband had moved to town close to a clinic. My mother in-law was not with us for her to prepare concoctions for me. I took my iron supplement daily, as ordered by the midwife. Unfortunately, labour started as early as 5am and continued to around 1am with severe pain. This current pregnancy, I go for antenatal every month but I do not take the iron supplement daily’.
PW15
‘I prefer to take concoction since I believe that it reduces pains during labour and facilitates delivery as against daily uptake of iron supplement’.
PW16
‘When I experience waist pain, I apply herbs, anima, which keeps us strong and active. Although I attend antenatal clinic every month for the supplement alright, I do not take them as prescribed. I come so that the midwife will check whether the position of the baby is good or not’.
PW20
Discussion
This study aimed to explore women's beliefs related to the daily uptake of iron supplements during pregnancy. The results showed that pregnant women had negative beliefs about daily iron supplements. This is similar to Nugraheni et al (2020), who found that more than 50% of pregnant women in Indonesia were classified as having negative beliefs about medications.
The participants reported the belief that daily uptake of iron supplements could cause fetal macrosomia, making it necessary to have either an episiotomy or caesarean section. Kamau et al (2018) and Raghavan et al (2013) also reported that some pregnant women were reluctant to take iron supplements because they believed it would make the baby ‘too big to be delivered’.
Although it has been reported that fetal macrosomia (weighing above 90th centile for gestation age) can cause difficulties in birth, and make it necessary to have an episiotomy or caesarean section (Ramsey et al, 2006; Macdonald and Magill-Cuerden, 2011), there is no evidence that this is caused by iron supplements. However, diabetes or obesity in the birth parent are known causes of fetal macrosomia (WHO and Food and Agricultural Organization of the United Nations (FAO), 2004; Said and Manji, 2016). It is therefore important that antenatal care providers are able to provide effective health education on iron nutrition and supplementation, and its association with positive health outcomes for a mother and fetus, in order to address misconceptions.
The present study reported that some pregnant women believed that daily iron supplements could lead to complications (such as bleeding and fetal malformation) during birth, as a result of the increased haemoglobin levels caused by iron supplements. Similarly, Mulder et al (2017) found that pregnant women's concerns regarding uptake of medication included fear of congenital birth defects as well as a wider range of adverse consequences. The WHO (2014) recommend the use of iron supplements as the most effective way to improve maternal haemoglobin levels and prevent anaemia in pregnancy (Mwangi et al, 2017), demonstrating that the participants had some understanding of the effects of iron supplementation.
There is a relationship between pregnancy complications and haemoglobin levels, with studies suggesting that complications increase with both low and high haemoglobin levels (WHO and FAO, 2004; Pavord et al, 2011). A booking haemoglobin level exceeding 14.5g/dl was linked with a 42% risk of subsequent hypertension in first-time mothers (Murphy et al, 1986; Pavord et al, 2011). There are potential clinical risks associated with iron supplementation in women who already have sufficient iron, including that an elevated haemoglobin level poses a risk of placental insufficiency and secondary haemochromatosis in women with iron-loading conditions (Pavord et al, 2011).
However, there is no evidence to suggest that elevated haemoglobin levels within the normal range for non-pregnant individuals have any adverse effects on pregnant women. Furthermore, for the majority of women in developing nations, physiological adaptations during pregnancy do not adequately compensate for the significantly increased iron demands that occur. This is often the result of low iron levels caused by frequent births and the low iron bioavailability in the diet (Funk et al, 2010). Daily uptake of iron supplements is therefore unlikely to cause haemoglobin to exceed the normal non-pregnancy range (Murray-Kolb and Beard, 2007). Rather than being the result of routine iron intake, increased haemoglobin levels beyond the standard non-pregnancy range is attributed to pathological hormonal and haemodynamic changes incited by an increased sensitivity to angiotensin II, a phenomenon observed in some pregnant women (WHO and FAO, 2004). Nonetheless, the somewhat unconventional need to supplement otherwise healthy pregnant women with additional nutrients such as iron and folate should be considered (WHO and FAO, 2004).
In light of the present study's findings regarding women's beliefs, in concert with corroborating results from other studies, it is crucial to provide pregnant women with information regarding labour bleeding and the potential impacts of iron medication on fetal health. Any concerns or apprehensions regarding potential risks related to supplements should be addressed and resolved during antenatal care, to promote informed decision making regarding compliance with supplement regimes.
Some of the present study's participants reported the belief that iron supplements cause nausea and vomiting. Mithra et al (2014) likewise found that some pregnant women experience stomach discomfort that ranges from heartburn to nausea and vomiting, which they attributed to daily iron supplementation. However, Macdonald and Magill-Cuerden (2011) reported that nausea and vomiting are common symptoms in pregnancy, occurring in up to 90% of normal pregnancies, especially during the first trimester of pregnancy and among first-time pregnant women. ‘Morning sickness’ is often regarded as normal and a presumptive sign of pregnancy, and is caused by physiological changes, not daily uptake of iron supplements. The majority of women who have nausea and vomiting in their first trimester go on to have normal, healthy pregnancies (Tierson et al, 1986; Weigel and Weigel, 1989; Lee et al, 2011).
It is important to note that pathological vomiting in pregnancy (hyperemesis gravidarum) can interfere with pregnant women's day-to-day activities and lead to weight loss, dizziness, dehydration and an imbalance of electrolytes (Holmgren et al, 2008). Healthcare professionals providing antenatal care to women can provide several recommendations to alleviate nausea, including to avoid prolonged periods of fasting, consume food in small portions at 1–2-hour intervals, opt for low-fat meals, avoid foods or odours that exacerbate nausea. Adequate hydration should also be emphasised, and the incorporation of ginger in the diet may provide some relief (Macdonald and Magill-Cuerden, 2011).
The present study's participants also reported the general belief that iron supplements were not as effective as traditional alternatives, such as herbal medicine. The belief that herbal medicine is more effective and will facilitate a quicker birth has been reported previously (Kalimbira et al, 2009; Raghavan et al, 2013). Tefera et al (2020) reported that pregnant women believed that medications, in general, were harmful and that herbal remedies were safe. There is a need for education on the possible negative effects of herbal medicines on the fetus and mother during pregnancy (Dwivedi and Chopra, 2013; Posadzki et al, 2013).
Strengths and limitations
A key strength of this study lies in the quality of the data collected; the study captured the perspectives of pregnant women regarding non-compliance with iron supplementation. This is pivotal in enhancing understanding and subsequently improving the provision of maternal care.
One limitation of this study is the small sample size, which impacts the generalisability of the results; they may not be representative of the broader population of pregnant women in the Tain District, the wider region where the study was conducted, or the country as a whole. Additionally, the study did not establish whether the participants' beliefs are recognised by prenatal care providers in the district.
Conclusions
This study explored pregnant women's beliefs surrounding daily oral iron supplements. Reported negative beliefs included that iron supplements increased the baby's size, leading to a subsequent increased need for episiotomy or caesarean section, that they could cause haemorrhage and malformation, that they caused nausea and vomiting, and that they were not as not effective as herbal medicine. Efforts are needed to educate pregnant women on the benefits of iron supplements and dispel misconceptions. Pregnant women should also be encouraged to obtain information regarding iron supplements and medication use during pregnancy from verified sources.
Key points
- Negative perceptions of iron supplements are associated with non-compliance to a daily regime, leading to increased risk of maternal anaemia, especially in low- and middle-income countries.
- The study participants were worried that daily iron supplements would increase their baby's growth to excessive levels, leading to cervical tears, episiotomy or caesarean section during labour and birth.
- Other concerns included that the supplements would cause excessive bleeding during labour, and nausea and vomiting during pregnancy.
- Several participants felt that herbal medicine, a traditional alternative to ‘Western medicine’ would be better than adhering to iron supplementation
- Education is needed to encourage pregnant women to adhere to iron supplementation and dispel misconceptions and misinformation.