Biopharm Journal.

 2015, 1(1), 33‐40              ISSN: 2454‐1397                           

RESEARCH ARTICLE
ANEMIA IN PREGNANCY: IMPROVING ADHERENCE WITH INTERVENTIONS
Bijoy Kumar Panda1*, Vaishali S Taralekar2, Aditya Mishra1, Priyanka Srivastava1
1Bharati Vidyapeeth Deemed University, Poona College of Pharmacy, Pune-411043, Maharashtra, India
2Department of Obstetrics and Gynecology, Bharati Vidyapeeth Medical College and Hospital, Pune, Maharashtra,
India.
[Received on: 03rd May, 2015 Accepted on: 26nd May, 2015 Published on: 28th May, 2015]
Abstract
1. Introduction
A prospective cross-sectional study conducted to
analyze and improve adherence pattern towards oral Throughout the world, particularly in developing
iron supplements in pregnancy with interventions. A countries, Anemia during pregnancy is a major
potential group study for the duration of 6 months public health problem. Though, most of the anemia
was carried in a tertiary care teaching hospital. 100 in pregnancy can largely be preventable and easily
pregnant subjects were randomly assigned in to treatable if detected in time, anemia still continues to
control and intervention group. Control group be a common cause of mortality and morbidity in
received prescription to purchase iron supplements India (Dutta, 2004; Tolentino and Friedman, 2007).
while intervention group was dispensed with free WHO recommends a cutoff value of 11.0 gm/dl for
oral iron supplements at each OPD visit. Both the hemoglobin to define at any time during pregnancy
groups were subjected to counseling at each visit. (Breyman, 2001). According to WHO report, the
Hemoglobin level adherence was assessed using anemia prevalence among pregnant women is 55.9%
Morisky 8 item Medication Adherence Scale world wide. In India, this prevalence has been
(MMAS-8) to monitor progress. The study observed reported to be in the range of 33-89% (Toteja, et al.,
significantly higher prevalence of anemia among 2006). Anemia ranges from mild, moderate to severe
pregnant women in low educated section, low and the WHO pegs the hemoglobin level in
economic status and increasing gravidity in both the pregnancy at 10.0-10.9 for each of these types of
groups. The mean adherence rate and hemoglobin anemia g/dl (mild anemia), 7-9.9 g/dl (moderate
levels were significantly high in intervention group at anemia) and <7g/dl (severe anemia) (De-Maeyer
fourth visit. Forgetfulness and side effects associated EM, 1989).
to iron therapy were the most common reasons for Current estimates from WHO (1993-2005) put
non-adherence in both the groups. Free iron prevalence of anemia at 41.8% among pregnant
supplements along with routine counseling by women, with the highest prevalence rate (61.3%)
pharmacist on follow up radically improved the found among pregnant women in Africa and 52.5%
adherence status to the medication thereby improve among South East Asia (Benoist, et al., 2008)
hemoglobin pregnant women. Lower education,
economic status and high gravidity were responsible Iron deficiency anemia detected in early pregnancy is
for higher incidence of anemia in such population. associated with lower energy and iron intake,
Key Words: Adherence, Iron deficiency anemia, Iron resulting in an inadequate gestational weight gain
supplementation, Morisky Medication Adherence over the whole pregnancy and a greater than two
Scale, Pregnancy. fold increase in the risk of preterm delivery. (Scholl,
---------------------- et al., 1992; Garn, et al., 1981) While many antenatal
*Correspondence care programs distribute iron supply to pregnant
Ph. no.: +919960350826 women, the effectiveness of these interventions in
Email id: pandabijoy@gmail.com reducing maternal anemia has been inadequate.
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Some suggest that poor compliance with iron
treatment is the possible reason for the
ineffectiveness of such program (Monow, 1990;
Abou-Zahr, 1990).
The standard for maternal and neonatal care
developed by the WHO has been working alongside
National Nutrition Anemia Prophylaxis Program in
India for pregnant women in order to impress
adherence to prescribed supplements (Elder LK,
2000; Lincetto, 2002). Causes of poor compliance
with iron supplementation program are low
accessibility and utilization of antenatal care,
insufficient and inappropriate counseling of mother,
lack of motivation of mother and failure of effective
screening and referral procedure in developing
countries (ACC/SCN, 1991).
To increase the compliance for iron tablets, there is
a need to develop approaches to address the
difficulties of adherence. A study indicated that
forgetfulness was a significant barrier for
consumption of iron tablets so researchers have
found that direct supervision had helped pregnant
women adhere to the iron tablets consumption
(Elder LK, 2000). It has been seen that certain
subset of population do not adhere to iron
supplements due to lack of awareness of effects iron
deficiency in pregnancy, nuclear family and
household workload which proves to be a burden
for sticking to the periodic procurement and regular
consumption of iron supplements. The primary
objective of this study was to document the effect
on adherence due to periodic counseling along with
distribution of free iron supplements and to monitor
the haemoglobin status of eligible pregnant women.
2. Materials and Methods
The prospective cross-sectional study was
conducted between Aug 2012- Jan 2013, in a tertiary
care teaching hospital with 100 pregnant women
randomized into two groups (50 participants in
intervention group and 50 in control group).
Pregnant women at the end of 1st trimester or
beginning of second trimester were included
randomly to either of the two groups in the study
after taking consent. Pregnant women with history
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of severe side effects to iron therapy, end of 2nd
trimester and/or third trimester, taking intravenous
iron supplements were excluded. The study was
approved by the Institutional Medical Ethics
Committee.
Demographic details were collected in a predesigned
format and information regarding per capita income
(in Rupees / month) was collected and socio-
economic status was classified using Modified B G
Prasad's classification for the study period (2012)
and it was calculated by Multiplication factor (2012)
with 1961 Prasad's classification values (Kulkarni
and Barde, 1998). Average consumer price index for
year 2012 was 209.33 (All India consumer price
index, 2012).
Each subject of both the groups was followed up
for 4 visits in an individualized manner at a
predetermined interval and the following tasks were
performed [Figure.1]:
Control group: Counseling and iron tablets
purchase by prescription
Intervention group: Counseling and dispensing of
free iron supplements
Visit-1: Informed consent, Medical history
collection, hemoglobin estimation and counseling to
both the groups while participants of intervention
group were distributed with free iron tablets till next
visit.
Visit-2: Adherence assessment, counseling,
hemoglobin estimation of both the groups while
intervention group were again dispensed with free
iron tablets till next visit.
Visit-3: Adherence assessment and counseling to
both the groups while intervention group were
dispensed with free iron tablets till next visit.
Visit-4: Evaluation of adherence and hemoglobin
levels for both the groups to monitor progress.
Medication adherence of the enrolled patients was
assessed by using Morisky 8-Item Medication
Adherence Scale (MMAS-8) (Morisky DE et al,
2008) consisted of 8 questions with score range of
0-8. In MMAS-8, <6 score considered as low
 
Biopharm Journal. 2015, 1(1), 33‐40              ISSN: 2454‐1397                           

adherence, 6-<8 as medium adherence and equal to The level of significance was set at a conventional 'p'
8 considered as high adherence. Routine one to one value of 0.01. Since the development measure of
verbal medication counseling was conducted as per
protocol at the scheduled OPD visits by a trained
clinical pharmacist.

Fig.1. Flow Chart of Study

adherence represents a categorical data with two
levels and the levels of hemoglobin, a continuous
measure, Chi-Square test and a Students unpaired t-
test was conducted respectively.
3. Results and Discussion
Demographic profile includes age at pregnancy,
educational status, economic status, type of diet,
type of family and occupation of study participants.
Table 1(a) and 1(b) shows correlation between
different socio-economic demographic parameters
and severity of anemia in both the groups. There
were 100 pregnant female participants. The age of
the study subjects varied from 18 to 37 years. Mean
age of the pregnant women was 23.96 ±3.20years.
There was no statistically significant difference
between intervention and control group in the
distribution of participants according to age,
educational status, economic status, type of diet,
type of family and occupation.
The study observed significantly higher prevalence
of anemia in both the groups among the pregnant
women with education less than graduation, low
economic status and high gravidity (P< 0.01). The
prevalence of anemia was relatively more in those
from nuclear family, those education is up to
primary and secondary levels and having vegetarian
diet. However, this observed reasons and difference
was statistically insignificant in both the groups.
The mean adherence rate and hemoglobin levels
were higher compared to the control group, across
all visits. The mean hemoglobin value of participants
in the intervention group during 1st visit was
9.4mg/dl, whereas in control group was 9.6mg/dl;
in the 2nd visit, mean hemoglobin level in the
intervention group was 10.4mg/dl and 10.2mg/dl in
the control group; in the 3rd visit, mean hemoglobin

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Biopharm Journal. 2015, 1(1), 33‐40              ISSN: 2454‐1397                           

was 11.7 mg/dl in the intervention group and In this study, there was statistically significant
11.1mg/dl in control group. There was statistical difference found in the distribution of participants
significant difference in the mean hemoglobin values according to anemic status, across both the groups
at visit 4 [Fig.2].
Table 1(a): Socio-demographic profile and Severity of Anemia of Control group

Degree of Anemia
Particulars Normal Mild Moderate Total P-value
N=24(%) N=15(%) N=11(%) N=50(%)
18-21 03(12.5) 04(26.6) 02(18.1) 09(18.0)
22-25 16(66.6) 07(46.6) 02(18.1) 25(50.0)
Age in Years 26-30 05(20.8) 02(4.0) 05(45.4) 12(24.0) P>0.01
> 30 00(00) 02(4.0) 02(18.1) 04(08)
Type of Nuclear 14(58.3) 08(53.3) 07(63.6) 29(58)
P>0.01
family Joint 10(41.6) 07(29.1) 04(36.3) 21(42)
Illiterate 00(00) 03(12.5) 00(00) 03(06)
Below Primary 03(12.5) 03(12.5) 06(54.5) 12(24)
Education Primary- 12(50) 06(40.0) 04(36.3) 22(44) P<0.01
Secondary
Graduate/Post 09(37.5) 03(12.5) 01(9.0) 13(26)
Graduate
Housewives 15(62.5) 11(73.3) 18(82.0) 44(88)
Occupation Service 01(4.1) 02(13.3) 01(9.0) 04(08) P>0.01
Laborer 00(00) 01(6.6) 01(9.0) 02(04)
Dietary Vegetarian 05(20.8) 04(26.6) 08(72.2) 17(34)
Mixed diet 19(79.1) 11(73.3) 03(27.2) 33(66) P>0.01
Habits
I 06(25.0) 00(00) 03(27.2) 09(18)
Socio-
Economic II 10(40.0) 07(46.6) 03(27.2) 20(40) P<0.01
Status III 08(33.3) 04(26.6) 04(36.3) 16(32)
IV 00(00) 04(26.6) 01(9.0) 05(10)
1-2 21(87.5) 10(66.6) 06(54.5) 37(74)
Gravidity 3-4 02(8.3) 05(33.3) 05(45.4) 12(24) P<0.01
>4 01(4.1) 00(00) 00(00) 01(02)

Fig. 2. Improvement in mean Hemoglobin (Hb) Fig.3. Improvement in Adherence to iron

level at each visit supplements at each visit

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Table 1(b). Socio-demographic profile and Severity of Anemia of Intervention group

Degree of Anemia
Particulars Normal Mild Moderate Total P-value
N=32(%) N=12(%) N=06(%) N=50(%)
18-21 08(25) 04(33.3) 00(00) 12(24)
22-25 15(46.2) 06(50.0) 02(33.3) 23(46)
Age in Years 26-30 P>0.01
07(21.8) 02(16.6) 02(33.3) 11(22)
> 30 02(6.2) 00(00) 02(33.3) 04(08)
Type of Nuclear 18(25) 9(75.0) 04(66.6) 31(62)
P>0.01
family Joint 14(43.7) 3(25.5) 02(33.3) 19(38)
Illiterate 2(6.2) 05(41.6) 03(50.0) 10(20)
Below Primary 4(12.4) 03(25.5) 01(16.6) 08(16)
Education Primary- P<0.01
15(46.8) 02(16.6) 02(33.3) 19(38)
Secondary
Graduate/Post
11(34.3) 02(16.6) 00(00) 13(26)
Graduate
Housewives 22(68.7) 11(91.6) 04(66.6) 37(74)
Occupation Service 06(18.7) 01(8.3) 00(00) 07(14) P>0.01
Laborer 04(12.4) 00(00) 02(33.3) 06(12)
Dietary Vegetarian 11(34.7) 07(58.3) 03(50.0) 21(42)
Mixed diet 21(65.6) 05(41.6) 03(50.0) 29(58) P>0.01
Habits
I 10(31.2) 01(8.3) 00(00) 11(22)
Socio-
II 07(21.8) 03(25.5) 00(00) 10(20)
Economic P<0.01
III 09(28.1) 05(41.6) 02(33.3) 16(32)
Status
IV 06(18.7) 03(25.5) 03(50.0) 12(24)
1-2 24(75.0) 07(58.3) 02(33.3) 33(66)
Gravidity 3-4 06(18.7) 02(16.6) 01(16.6) 09(18) P<0.01
>4 02(6.2) 03(25.5) 03(50.0) 08(16)

Table 2: Comparison of anemia at each visit

Control: Anemic Intervention: Anemic

Visits p-value
Mild Moderate Total (%) Mild Moderate Total (%)
1 15 11 26(52) 15 09 24(48)

2 12 10 22(44) 11 09 20(40) P>0.01

4 06 08 14(28) 03 02 05(10)

on 4th visit while insignificant difference on 1st &
2nd visit. Prevalence of anemia in intervention
group was 48% at 1st visit, 40% at 2nd visit and
further reduced to 10% at 4th visit; whereas in
control group at 1st visit 52%, at 2nd visit 44% and
at 4th visit 28% [Table 2].
Adherence rate for the groups were compared and
statistically significant difference was observed from
3rd visit onwards.
The mean adherence rate in study during 2nd visit
was 57.4%. However, in the control group it was

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Biopharm Journal. 2015, 1(1), 33‐40              ISSN: 2454‐1397                           

53.1%. Likewise, during 3rd visit mean adherence Discussion:

rate was 76% in intervention group compared to
The prevalence of anemia among pregnant women
68% in control group. Subsequently, in 4th visit, the
in our study was half the participants enrolled,
adherence rate was 86.5% in intervention group and
which was similar various other Indian studies
77.5% in control group [Fig. 3].
(NFHS-3, 2006; Panghal et al, 2010). However,
higher prevalence of anemia was also reported by
several studies (Kapil U et al, 1999; Toteja GS et al
2006; Scholl, et al., 1992; Gautam VP et al, 2010)
Significantly lower prevalence of anemia among
pregnant women has been reported by similar
studies conducted in other countries like South-east
China (39.6%),(Kapil, et al., 1999) Venezuela
(34.44%), (Gautam, et al., 2010) South Eastern
Nigeria (40.4%), (Jin, et al., 2010) Isparta
Province(42.71%), (Arturo, et al., 2002) Tanzania
(36.1%).( Dim, et al., 2007)
The prevalence of anemia was significantly more in
Fig.4. Reasons for non compliance those above 35 years of age and those from below
During adherence assessment reasons for non Class III socio-economic status (Kisioglu, 2004),
adherence/ missing the doses were also assessed. similar to that reported by Gautam V P et al., 2010.
In our study mean age of the subjects at the time of
Forgetfulness and side effects associated to iron
the study was found to be 23.96±3.26 years and
therapy were the most common reasons for non-
60% were from nuclear families. In a study by
adherence followed by bad taste, medicine phobia
Agarwal et al, 2008, half of the study subjects were
and traditional beliefs of not taking medicine during
between 22-24 years of age and 58.3% were from
pregnancy [Fig.4].
nuclear families, while 1/3rd were educated up to
Nausea and vomiting were the most common side primary level only. In our study mean hemoglobin
effects observed followed by heartburn, diarrhea, level among the pregnant women was
constipation, abdominal pain etc. observed in 10.59±1.05gm/dl ranging between 8.1 to 13.1
pregnant women taking iron supplementation in gm/dl. Mengi V et al., 1988 reported 10.19 + 1.5
both the groups. These side effects could be gm/dl (ranging between 6.5 to 13.2gm/dl), while
associated with iron supplements [Table 3]. that in other countries was found to be 10.76 + 1.66
Table 3: Side effects experienced during iron gm/dl in a study at Isparta Province (Arturo, et al.,
therapy 2002) and 11.9 + 1.4gm/dl at Venezuela (Gautam V
Control Intervention P et al., 2010). As in other studies (NFHS-3, 2006;
Side effects
N=50(%) N=50(%) Kapil U et al, 1999; Agarwal T et al 2008), severity
Nausea 12(24) 9(18) of anemia was inversely related to educational status
Vomiting 13(26) 6(12) and socio-economic status as stated by Panghal et al,
Heartburn 5(10) 4(08) 2010. Anemia was more often seen among pregnant
Diarrhea 4(08) 2(04) women aged more than 25years, from nuclear
Constipation 3(06) 2(04) families educated till high school or less and parity
Abdominal pain 2(04) 0(00) two or more. These factors could be taken care by
Others 2(04) 3(06) timely health education to adolescent girls regarding
importance of literacy, proper age at marriage,
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Biopharm Journal. 2015, 1(1), 33‐40              ISSN: 2454‐1397
family spacing, small family norm etc. The pregnant
women along with the family representative require
an educational awareness on the anemia and effects
of anemia on fetus and mother will definitely
improve the anemic condition. Although statistically
not significant, prevalence of anemia was seen to
increase with increase in parity and advancing
gestational age (Arturo, et al., 2002; Hinderaker S.G,
2001; Kapil U et al, 1999).
The low adherence was particularly due to the
medication factors such as side effects (nausea,
vomiting and stomach upset) associated with iron
preparations, patient factors predominantly
forgetfulness. Addressing the concerns of a pregnant
women from a nuclear family can maintain the
healthy status of hemoglobin level as, such women
are lonely and busy with household work which do
not allow them to procure and consume medication
on time. The counseling at periodic visits to both
the groups brought a significant increase in
adherence to the iron supplements. In our study the
low adherence could be attributed to the low socio-
economic (Class IV & III) condition and due to
counseling and free dispensing of iron tablets on
periodic visits to such low socio-economic class of
patients brought a significant improvement in
hemoglobin level in the intervention group. Apart
from all the determinants stated the adherence to
iron supplements can be achieved in special socio-
economic sections of pregnant women through free
access to iron supplements with intensive
counseling.
4. Conclusion:
Free iron supplements along with routine counseling
by pharmacist on follow up dramatically improved
the adherence status to the medication thereby
improving hemoglobin in pregnant women. Lower
education, economic status and high gravidity were
responsible for higher incidence of anemia in such
population.
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5. Limitation:
Measurement of serum ferritin or serum transferring
levels could have given better diagnosis of iron
status in the pregnant women. This could not be
done because of logistic and feasibility issues.
6. Acknowledgement:
We would like to thank to Bharati Hospital
administration and Staff of Department of
Obstetrics and Gynaecology, other allied health
professionals for their valuable cooperation in
conducting this study.
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