Aditi Chaudhary,Monaliza,V.Venkadalakshmi,Sujata Siwatch


Background: Vitamins and minerals are essential for normal function, growth and development. Minerals have important effects on the health of the mother and fetus. Supplements deciency during pregnancy can lead to anemia, hypertension, obstetric complications and even maternal death and in fetus it can lead to a failure in normal growth and development. These complications can be prevented by supplementing needed vitamins and minerals during the course of pregnancy

Objective: To assess the adherence of supplements among antenatal women.

Methodology: Quantitative approach and descriptive research design was used. Total 71 Antenatal mothers of second trimester onwards who visited Antenatal Clinic (ANC), PGIMER, Chandigarh during July – August, 2019 were enrolled by total enumeration sampling technique. Data was collected by using interview schedule comprising of (a) Sociodemographic prole (b) clinical prole and obstetrical prole and (c) SMAQ (Simplied Medication Adherence Questionnaire).

Results: Two third (64.8%) of antenatal mothers were non adherent to the nutritional supplements. Reason for non-adherence included forgetfulness (91.5%), carelessness (56.3%) and worst feeling associated with intake of nutritional supplement (50.7%).

Conclusion: Non- adherence of supplements is a major challenge among antenatal mothers and forgetfulness is the major reason for non-adherence.

Key words: Adherence, Antenatal women, Nutritional Supplement adherence

Address for correspondence:

Dr. Monaliza Lecturer, NINE PGI, Chandigarh.


Vitamins and minerals are essential for normal function, growth and development. Minerals have important effects on the health of the mother and fetus. The deciency during pregnancy can lead to a n e m i a , h y p e r t e n s i o n , o b s t e t r i c complications and even maternal death and in fetus can lead to failure in normal growth

and development. During Pregnancy body undergoes major changes. These changes may affect body shape, physiology and metabolism. Changes include increased blood volume, heart rate, blood pressure, lung function and urine production by the kidneys and also result in reduction of the movement of the digestive tract. Good nutrition and lifestyle are important to give ‘the best possible’ pregnancy outcome for mother and baby. Vitamin B12, folic acid, Iron and Calcium are required for normal development of body tissues (DNA synthesis), particularly by rapidly tu over cells such as red blood cells which are constantly being replaced. Iron is an essential part of hemoglobin.1,2

Low folate levels at the time of conception are related to increased chances of development of baby having defects in developing spinal cord. These abnormality can lead to the baby being born with Spina bida where the spinal vertebral covering in the lower back region generally is incomplete. Iron deciency and anemia during pregnancy is a major health problem in many developing countries. Women may have an inadequate diet and have other factors such as malaria, worm (helminthic) infestations, poor sanitation and drinking water which contribute to the increased risk of illness and death of mothers and their newborn babies. If a pregnant woman has low hemoglobin levels, she may also be more likely to give birth prematurely and have a low birth weight baby. Iron deciency and anemia in newborn infants can impair the infant’s cognitive and intellectual development and physical growth (WHO 2012).3-5

Iron-folic acid deciency increases the risk of blood loss during labor, maternal mortality, preterm delivery, low birth weight, and perinatal mortality. Mortality and morbidity of the mother and the baby is associated with maternal anemia including risk of miscarriages, stillbirths, prematurity and low birth weight. This impairs child development and also learning too, further impacting economic productivity and development.6 Adequate nutrition in pregnancy is essential for maternal health and positive birth outcomes. However, traditional diets in m a n y l o w – i n c o m e c o u n t r i e s a r e suboptimal, and additional individual and socio-cultural factors such as food aversions and eating less food in pregnancy can further reduce the intake in pregnancy. Nutrient supplements can help ll this gap and may improve pregnancy outcomes. The World Health Organization (WHO) currently recommends daily iron and folic acid (IFA) supplementation in pregnancy but coverage in most countries remains low. M u l t i p l e m i c r o n u t r i e n t ( M M N ) supplements have been shown to be more effective than IFA alone on improving birth outcome but it is not yet recommended by the WHO, the standard of care and utilization remains low. All three supplements (iron, folic acid and calcium) must be consumed on a daily basis throughout  pregnancy    to    optimize e f f e c t i v e n e s s a n d a s a r e s u l t o f understanding factors inuencing acceptability and utilization of these supplements by pregnant women remains a crucial component to improve maternal health outcomes.3,7

I ron supplementation i s the most commonly used strategy to control iron deciency among pregnant women in developing countries. Although iron supplementation is an inexpensive and effective way of increasing hemoglobin levels during pregnancy but is still a major problem in developing countries. It is estimated that more than 40% of pregnant women worldwide are anaemic. At least half of this anaemia burden is assumed to be due to iron dciency.8,9

D a i l y o r a l i r o n a n d f o l i c a c i d supplementation with 30 mg to 60 mg of elemental iron and 400 µg (0.4 mg) folic acid is recommended for 100 days to p r e g n a n t w o m e n . D a i l y c a l c i u m supplementation (1.5g–2.0g oral elemental calcium) is recommended for pregnant women to meet the Calcium requirement during pregnancy. Despite of the prescription and free distribution of Iron and Folic acid tablets large number of pregnant women are anaemic. This may be due to non adherence to prescribed supplements. Hence measuring compliance and adherence to supplementation is important.10,11

Material and method

A Descriptive study was conducted in Antenatal Clinic, PGIMER Chandigarh. Total enumeration sampling technique was used for enrolling 71 antenatal mothers visiting to antenatal clinic during July to December 2019. Tools used for data collection was interview schedule comprising of (a) Sociodemographic prole (b) clinical prole and obstetrical prole and ( c) SMAQ ( Simplied Medication   Adherence    Questionnaire). S i m p l i  e d m e d i c a t i o n a d h e r e n c e questionnaire is available in open domain for the use of researchers. It comprises of 6 Questions to assess the adherence and reason for non- adherence.11 Tools were validated by the experts in the eld of Nursing,

Obstetrics and Gynecology, Dietics Department.. Written permission was taken from Head of Department, Obstetrics and Gynecology, PGIMER, Chandigarh for conducting study. Ethical approval was taken from Institute Ethics Committee, PGIMER, Chandigarh .

Data was collected in the period of July to December 2019. Antenatal women were approached during their clinical visit in antenatal clinic, outpatient department (OPD) Antenatal mothers were informed about the purpose of study and written consent was taken from them. Mother was interviewed in a nursing room of OPD to maintain privacy and provide comfortable environment. Approximately half an hour is spent with mother to gather the required data from mother. Data was analyzed by using descriptive statistics with the help of SPSS (SPSS version 20.0).


Table1depicts the socio demographic characteristics of antenatal mothers enrolled in the study. One third of subjects were in the age group of 26–30 year (36.6%). The mean age was 27.89 years. One antenatal mother was separated rest all were living with their partners. Out of total 25.4% were graduate. Furthermore, most of antenatal mothers (84.5%) were house wives. Two third of the antenatal mothers were from rural area (63.4%). Most of the study participants (77.5%) were from Hindu community and were living in joint families (69%). Majority (91.5%) of them had per capita income less than Rs. 20,000/-

Table 2 depicts that 59.2% mothers were multigravida and 40.8% were primigravida. Menstrual cycle of most antenatal mothers (71.8%) was 3-4 days, and have an average amount of blood ow (74.2%). Most of them (80.3%) had regular menstrual pattern.

Ta b l e 1 :     S o c i o – d e m o g r a p h i c characteristics of study participants

Variables Control Group (n2= 71)

F (%)

Age (years)





25 (35.2)

26 (36.6)

12 (16.9)


Marital status Married Separated 70(98.6)


Educational status of mother


Less than primary Primary

High school Secondary Graduate

Post Graduate








Occupation of mother Housewife Government job Private job






Habitat Urban Rural 26(36.6)


Religion Hindu Muslim Sikh 55(77.5)



Family type Nuclear Joint 22(31.0)


Per capita income

< 20,000

20,000- 60,000




N = 71

consumed 1 glass of milk /day. One third of antenatal mothers were not in the habit of consuming tea ( 39 . 4 %) and same proportion (39.4%) of antenatal mothers were not in the habit of taking milk after 1 hour of meals whereas tea was consumed before meals by 26.8% antenatal mothers. Fruits and vegetables were consumed daily by most of antenatal mothers (74.6%) and nearly half of them had single serving of fruits daily (46.5%). Half of (50%) antenatal mothers were not consuming junk foods. Only 31% use to take two liters of water daily.

Table 2: Obstetrical and menstrual history of study participants


N= 71

Variables Control Group n= 71

f (%)

Primigravida 29(40.8)
Multigravida 42(59.2)
Duration of menstruation (days)  
1-2 4(5.6)
3-4 51(71.8)
5-6 16(22.5)
Amount of blood flow (no. of pads)  
Scanty (1-2) 11(15.5)
Average (2-3) 52(73.2)
Heavy (3-4) 08(11.3)
Menstrual pattern  
Regular 57(80.3)
Irregular 14(19.7)



Table 3a, 3b reveal that 56.3% antenatal mothers were vegetarian. Most of antenatal mother did not observe fast (85.9%) and 49.3% consumed meals thrice a day. Majority of antenatal women (80.3%) did not skip any meals. Nearly 38.0% mothers

Table 4 shows the scores of study subjects related to adherence of nutritional supplements as per Simplied medication adherence questionnaire. The study participants reported that they usually forget to take medication (91.5%), were careless for taking their medication (56.3%) and stop taking medication when feel worse (50.7%). The participants have skipped medicine 1-2 times since last week (62.0%) and have not taken their medicine since last weekend (32.4%). The two third (64.8%) study participants had skipped medicine more than 2 days in 3 months. So, we can conclude that more than half of the antenatal mothers were non adherent to nutritional supplements (Iron, Calcium & Folic acid)

Table 3(a): Dietary habits of participants

N= 71

Table 3(b): D ietary habits of participants (continued)


Variables Control Group n= 71

f (%)

Tea intake time Before meals With meals

1 hour after meals




Fruit intake (days/week)

7 days 3days 2days

once a week





No. of serving of fruit  
1 serving
2 serving 25(35.2)
3 serving 08(11.3)
Vegetable intake

Never Daily

Alternative day 3 times per week 2 times per week



Non-Veg Intake  
1 per week
twice per week 01(1.4)
once a month 11(15.5)
No intake 45(63.4)
Eating meals Outside


Once a month Twice month Thrice month Once week

2 times a week







Junk food intake

Never Sometimes Often

Water intake  
1 litre 21(29.6)
1.5 litre 19(26.8)
2 litre or above 22(31.0)


N= 71


Variables Control Group n= 71

f (%)

Dietary habits Vegetarian Non vegetarian Eggetarian  




Observes Fasting during pregnancy

No Yes




Fasting duration Up  to dinner Upto next day  



No. of meals/day

One Two Three Four Five









Skipping of meals

Breakfast Lunch

No meals skipped




Milk consumption

Never Sometimes 1 glass daily

2  glasses daily

3  glasses daily







Tea consumption

Never Sometimes 1 cup daily

2  cups daily

3  cups daily







Milk intake time Before meals With meals

Immediately after meals

1 hour after meals








 Table 4: Medical adherence as per Simplified Medication Adherence Questionnaire


  ITEMS Score n(f%)
1 Ever forget to take medications 65(91.5)
2 Careless at times about taking medications 40(56.3
3 At time feel worse, and stop taking medications 36(50.7)
4 Since last week, often have not taken medicine

1-2 times

3-5 times




5 Not taken medicine since last week-end. 23(32.4)
6 Days in past 3 months not taken any medicine at all.







N u t r i t i o n s u p p l e m e n t s a r e t h e micronutrient that are required to meet the increased nutrition demand during pregnancy such as Iron, folic acid, and calcium. Major physical changes a woman experiences during pregnancy occur mostly during the second trimester as the uterus and abdomen expand. The second trimester requires essential nutrients to support growth of developing fetus. Dietary habit of the antenatal women is not sufcient to meet the micronutrient requirement of antenatal mother and developing fetus. So, supplements play a vital role to prevent micronutrient deciency. Despite of recommendation and free distribution of iron, calcium and folic acid for 100 days during pregnancy women are still facing micronutrient deciencies and often suffers anemia during pregnancy due to non- adherence of nutritional supplements3 Hence it is important to assess the adherence of nutritional supplements among pregnant women SMAQ (Simplied medication Adherence Questionnaire) is a tool used to assess the adherence. It is a 6-item questionnaire that is used to assess the adherence and the reason for non-adherence. Ortega et. al conducted research on validation of SMAQ and concluded that Questionnaire provides good level of validity and inter observer agreement. In the study researcher also used Morisky- Green scale to compare the results of SMAQ. SMAQ provides higher sensitivity and lower specicity than Morisky- Green scale. A higher sensitivity is advantageous in a tool as it provides greater power of detection of non- complaint subjects and thus leads to better clinical follow up. Moreover, SMAQ is a free of cost. So SMAQ scale is chosen for this research study for assessing the adherence of antenatal mothers.11

Nutrition is a vital part of pregnancy. Well- balanced diet is recommended to pregnant women that is rich in vitamins, minerals, carbohydrates, protein and micronutrients. Good dietary practices help in meeting the nutrient requirement of mother and the developing fetus. So, it is an important aspect which cannot be neglected during pregnancy. Hence in present study dietary practices of antenatal mothers were assessed. It is recommended to have small frequent meals and not to keep fast during pregnancy. It was good to note that in present study most of the mothers were taking three meals a day but still few mothers (15%) were skipping their breakfast and lunch due to feeling nauseated with the aroma of food and few of them were fasting during pregnancy because they have strong spiritual belief related to fasting whereas some mothers told that they cannot skip some important fasting days as it is their family practice .It is good to know that there were few women ( 17 %) who were following the dietary recommendations and having small and frequent meals i.e., 5-6 times a day.

Milk is a good source of calcium, vitamins and is important component of diet of pregnant women. In the present study one third of mothers were not including milk in their diet and told that they don’t like having milk and were not taking even before the pregnancy. But there were few mothers who were taking up to 3 glasses of milk. It is good to note that in the present study majority of mothers were including fruits and vegetables daily in their diet but still there were small number of antenatal mothers (4%) who were not including vegetables in the diet because they were not liking the taste and feel nausea.

Milk and tea interfere with the body ability to absorb iron from food supplements. So, these products must be avoided to be taken with meals. In the present study we have noted that some women are taking milk and tea along with meals which is considered as wrong dietary practice. According to the responses of the participants 64.8% of women were non adherent to supplements and forgetfulness of medication is the major reason of the antenatal mothers for non-adherent to medication. Similar ndings were reported in the study conducted by Taye B. et al. (2015) on compliance of iron and folic acid indicate that the proportion of women taking iron and folic acid supplementation is much lower.12

In the similar lines Clermont A. et al (2018) in their study concluded that despite a stated high level of acceptance and enthusiasm for the supplements among pregnant women and their household members, it is clear that certain fears and side effects impacted utilization. In the current study we have found that nearly half of women are non adherent due to worse feeling associated with medication. They feel acidity, nausea after taking iron tablet.13

It is concluded that the supplements are essential during pregnancy and the adherence to supplements is a major challenge faced. Iron deciency anemia can be minimized during the pregnancy by i m p r o v i n g t h e a d h e r e n c e t o t h e supplements to reduce anemia related complications. Further studies can be conducted on strategies to improve adherence of supplement.


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