This study examined individual and facility-level factors associated with iron and folic acid (IFA) receipt and consumption among pregnant women in Bihar, India. The study found that higher quality antenatal care, as measured by practices and counseling, was positively associated with both IFA receipt and consumption. Receipt was also associated with earlier antenatal care enrollment and more visits. Consumption was more likely when the local health sub-center had IFA in stock. Significant variation between health facilities remained after accounting for individual factors. Ensuring consistent IFA supply and high quality antenatal care is important for improving IFA outcomes.

1. Antenatal care measures increase iron and
folic acid receipt and consumption among
pregnant women in Bihar, India
Amanda Wendt, Melissa Young, Rob Stephenson, Amy
Webb Girard, Usha Ramakrishnan, Reynaldo Martorell
Nutrition and Health Sciences, Laney Graduate School, Emory University
Institute of Public Health, University of Heidelberg, Germany*

2. Amanda Wendt, PhD MS
Alexander von Humboldt
Postdoctoral Research Fellow
Institute of Public Health
University of Heidelberg
Germany

3. Anemia: A global health issue
 Iron deficiency is one of the most common causes of anemia
 Almost one third of the world’s population suffers from anemia
– 1.62 billion
 9 out of 10 live in developing countries
World India Bihar
Women
(15-49y)
30% 48% 60%
Pregnant
Women
38% 54% 58%
WHO: Global anemia prevalence and trends; NFHS-4; Stevens et al, 2013

4.  Government of India Policy
 100mg/day for at least 100 days starting after first
trimester & 100 days post-partum
Iron and Folic Acid (IFA)
Guidelines
Kapil, 2014

5. Maternal Health Indicators Bihar
Maternal Mortality Ratio 274
Any Antenatal Check-Up 85%
3+ Antenatal Care (ANC) visits 37%
At least one Tetanus Toxoid
(TT)
85%
Consumed IFA for 100+ days 13%
Maternal Health in Bihar
Annual Health Survey, 2012-3

6. Rationale
 Previous studies focus on individual factors of IFA adherence
 IFA distribution and counseling are implemented through
government facilities and health workers
 Facilities may impact success of IFA receipt and consumption
among women

7. Study Objective
 Objective: To examine individual and facility-level
determinants of IFA receipt and consumption among pregnant
women in rural Bihar
 Hypothesis: IFA receipt and IFA consumption will be associated
with facility level factors as well as individual factors

8. Survey & Sample
 District Level Household Survey Round 3, 2007-08
 Cross-Sectional
 Representative at national, state, district level
 Multi-stage stratified probability proportional to size
sampling design

9. Final Study Populations: Flowchart of Exclusions of
Ever-Married Women
46,840 ever-married women (DLHS-3: Bihar)
21,633 women who had an index pregnancy in the study period
12,609 women who received antenatal care
12,420 women with complete data
Women covered by one Health Sub-
Center (HSC) (n=7,765)
21,331 women who had live birth in the study period
Women who received IFA
(n=2,905)
Sample A
Outcome: IFA Receipt
Sample B
Outcome: Adequate
IFA Consumption

10. Key Variables
 Outcomes:
 IFA Receipt
 IFA Consumption
 Individual Level Variables:
 Age
 Age of Marriage
 Maternal Education
 Gender Composition of Living
Children
 Birth Order of Index Pregnancy
 Caste
 Religion
 Wealth Index Quintiles
 ANC Timing & Frequency
 ANC Factors
 ANC Practice
 ANC Counseling
 Facility Level Variables:
 Health Sub-Center(HSC) Factors
 Village Health Day &
Monitoring
 Personnel
 Infrastructure
 IFA Supply
 Distance to Nearest HSC

11. Factor Analysis
 Purpose: to reduce the number of variables
 Antenatal Care: 13
 Heath Sub-Center: 9
 Principal components analysis
 Orthogonal rotation – varimax method
 Polychoric correlation matrices
 More accurate correlations between categorical variables

12. Characteristics and Rotated Factor Loadings for Antenatal Care Factorsa
ANCb Practices ANCb Counseling
Eigenvalue 7.16 1.60
Proportion Variance Explained 0.73 0.16
Rotated Factor Loadings
Blood Tested 0.87 -
Weight Measured 0.81 -
Abdomen Examined 0.81 -
Sonogram/Ultrasound Taken 0.80 -
Breast Examined 0.76 -
Height Measured 0.76 -
Delivery Date Given 0.72 -
Importance of Cleanliness at Delivery - 0.83
Better Nutrition for Mother and Child -
0.80
Family Planning for Spacing - 0.75
Breastfeeding - 0.75
Importance of Institutional Delivery - 0.73
Nutrition Advice - 0.59
a Factor loadings ≤|0.5|
are not shown.
b ANC: Antenatal Care

13. Characteristics and Rotated Factor Loadings for Health Sub-Center Factorsa
Village Health
Day: Support &
Monitoring
Personnel
Characteristics
Sub Center
Infrastructure
Eigenvalue 1.10 0.63 0.54
Proportion Variance Explained 0.42 0.24 0.21
Rotated Factor Loadings
Observation of any Village Health Day 0.56 - -
Written feedback from PHCc 0.50 - -
VHSCd present in some villages in HSCb area 0.42 - -
Medical Officer visited HSCb in previous month 0.36 - -
Received and utilized untied funds from previous financial
year -
0.37
-
HSCb Personnel - 0.46 -
HSCb Training - 0.44 -
Present Condition of Existing Building - - 0.44
Water Available at Sub Center - - 0.43
a Factor loadings ≤|0.35| are not shown; b Health Sub-Center; c Primary Health Center; d VHSC: Village Health and
Sanitation Committee

14. Individual Level Factors of Study Population by Prevalence of Iron and
Folic Acid Receipt and Consumption
Received Any IFA
(Sample A)
Consumed IFA for 90+ Days
(Sample B)
Chi-Square Chi-Square
N % p-value N % p-value
Overall 7765 37.4 2905 23.8
Age
<20 y 1237 37.8 <0.0001 1148 22.4 0.2352
20-24 y 3071 42.0 468 23.1
>24 y 3457 33.2 1289 25.2
Mother's Education
None / Don't Know 4812 28.7 <0.0001 1382 14.6 <0.0001
1-4 y 610 36.7 224 18.3
5-8 y 1202 46.5 559 25.9
≥9 y 1141 64.9 740 40.8
Wealth Index Quintiles
Poorest 2154 26.5 <0.0001 571 13.0 <0.0001
Second 3061 33.4 1023 19.3
Middle 1510 44.4 671 23.3
Fourth 835 59.0 493 37.8
Richest 205 71.7 147 52.3

15. Individual Level Factors of Study Population by Prevalence of Iron and Folic Acid Receipt
and Consumption
Received Any IFA
(Sample A)
Consumed IFA for 90+ Days
(Sample B)
Chi-Square Chi-Square
N % p-value N % p-value
Overall 7765 37.4 2905 23.8
ANC Timing & Frequency <0.0001 <0.0001
Early Enrollment & ≥4 ANC Visits 837 71.7 600 49.5
Late Enrollment & ≥4 ANC Visits 215 63.7 137 40.9
Early Enrollment & <4 ANC Visits 2232 40.3 900 17.6
Late Enrollment & <4 ANC Visits 4481 28.3 1268 14.1
ANC Practices <0.0001 <0.0001
None 3903 19.2 749 9.2
1-3 2630 48.9 1287 19.6
4-7 1232 70.5 869 42.4
ANC Counseling <0.0001 <0.0001
None 2841 21.3 605 15.4
1-3 3376 41.0 1385 20.4
4-6 1548 59.1 915 34.3
IFA: Iron and Folic Acid; ANC: Antenatal Care; Early Enrollment: 1st
trimester; Late Enrollment: 2nd
– 3rd
trimester

16. Multilevel Modeling of Any IFA Receipt During Last Pregnancy (Sample A)
Parameter
All Factors +
Interactions
Parameter
All Factors +
Interactions
OR (95% CI) OR (95% CI)
Age of Marriage Antenatal Care Timing and Frequency
<18 y ref Early enrollment and ≥4 visits 3.53 (2.44, 5.11)
≥18 y 1.21 (1.05, 1.39) Late enrollment and ≥4 visits 2.44 (1.69, 3.51)
Mother's Education Early enrollment and <4 visits 1.36 (1.19, 1.55)
None / Don't Know ref Late enrollment and <4 visits ref
1-4 y 0.98 (0.79, 1.21) Antenatal Care Factors
5-8 y 1.26 (1.06, 1.49) Practice 13.12 (9.51, 18.09)
≥9 y 1.67 (1.35, 2.06) Counseling 2.61 (2.12, 3.21)
Religion Practice*Counseling Interaction 0.37 (0.25, 0.56)
Hindu ref Timing & Frequency * Practice 0.68 (0.56, 0.82)
Muslim & Others 0.79 (0.66, 0.94) Community Level Random Effect (SE) 0.6259 (0.0473)
Wealth Index Quintiles
Poorest ref
Second 1.12 (0.97, 1.29)
Middle 1.16 (0.97, 1.39)
Fourth 1.30 (1.03, 1.64)
Richest 1.31 (0.87, 1.97)
ANC: Antenatal Care; HSC: Health Sub-Center; PHC: Primary Health Center; SE: Standard Error; AIC: Akaike Information Criterion; Factor ORs reflect a 1-unit change
Also adjusted for: age, gender composition of living children, birth order, caste, husband’s education, HSC Factors, IFA stock out, Distance to nearest HSC

17. Multilevel Modeling of IFA Consumption for 90+ Days During Last Pregnancy (Sample B)
Parameter All Factors Parameter All Factors
OR (95% CI) OR (95% CI)
Mother's Education Antenatal Care Timing and Frequency
None / Don't Know ref Early enrollment and ≥4 visits 3.4 (2.52, 4.59)
1-4 y 1.05 (0.68, 1.62) Late enrollment and ≥4 visits 3.19 (2.03, 5.01)
5-8 y 1.31 (0.95, 1.80) Early enrollment and <4 visits 1.05 (0.81, 1.37)
≥9 y 1.75 (1.24, 2.48) Late enrollment and <4 visits ref
Caste Antenatal Care Factors
Scheduled Castes & Tribes 0.71 (0.53, 0.97) Practice 2.62 (1.86, 3.71)
Others ref Counseling 1.08 (0.83, 1.4)
Wealth Index Quintiles IFA Available on Day of Survey
Poorest ref Yes 1.37 (1.04, 1.82)
Second 1.18 (0.84, 1.66) No ref
Middle 0.96 (0.65, 1.4)
Fourth 1.31 (0.86, 2.00) Community Level Random Effect 0.781 (0.108)
Richest 2.05 (1.17, 3.56)
ANC: Antenatal Care; HSC: Health Sub-Center; PHC: Primary Health Center; AIC: Akaike Information Criterion; Factor ORs reflect a 1-unit change;
Also adjusted for: age, age of marriage, gender composition of living children, birth order, religion, husband’s education, HSC Factors, Distance to
nearest HSC

18. Summary
 IFA Receipt
 All ANC components were significantly, positively associated
with odds of IFA receipt
 No health sub-center factors were significant
 Significant variation remained among facility sites
 IFA Consumption
 ANC practice and frequency were significantly, positively
associated with odds of IFA consumption
 Women were more likely to consume IFA for 90+ days when
their HSC had IFA in stock
 Significant variation remained among facility sites

19. Limitations & Strengths
 Limitations
 Variables based on self-report
 IFA supply based on availability on the day of survey
 High use of private sector for ANC and IFA purchasing
 All women attended ANC
 Did not have data on IFA counseling
 Strengths
 State representative dataset
 ANC quality factors
 Health Sub-Center capacity factors
 Health Sub-Centers were linked to the women they serve
 Multilevel modeling

20. Conclusions and Implications
 Measuring ANC quality can reveal insight on how ANC is associated with
outcomes more than timing & frequency alone
 ANC quality should be measured when assessing any singular ANC service
 ANC interactions may show a quality threshold in terms of IFA receipt –
highlighting the importance of services and counseling during initial
appointments
 IFA supply does play a role in successful IFA consumption
 A consistent supply must be ensured to support adequate IFA consumption
 Variation between sites may indicate facilities and/or communities do impact
IFA receipt and consumption beyond the individual level