Iron–Folic Acid Supplementation in Women of Reproductive Age

Iron–folic acid (IFA) supplementation during or before pregnancy can effectively reduce the risk of iron deficiency and anemia and improve gestational outcomes (Peña-Rosas and Viteri 2009).

Pre-conception: IFA supplementation before pregnancy can improve birth outcomes, increasing the iron and folic acid status in women pre-pregnancy, while addressing the iron deficiency that affects some menstruating women and adolescents (WHO 2009; WHO 2016a). Women of reproductive age (including adolescents) can be given oral IFA supplementation for three consecutive months, either daily or weekly, depending on the anemia prevalence rates in the setting (Table 4). Always consider the intervention in the context of other interventions to avoid exceeding daily iron requirements (e.g., mass fortification of staple foods) (WHO 2009).

Table 4: IFA Supplementation Recommendations for Women of Reproductive Age

Anemia Prevalence Among Women of Reproductive Age Recommendation
20–40% 120 mg iron + 2,800 mcg folic acid weekly
>40% 30-60 mg iron + 400 mcg folic acid daily for three consecutive months

Source: WHO 2009; WHO 2016a

Pregnancy: Women face increased iron requirements during pregnancy, and folic acid is necessary for the healthy development of the fetus. In the antenatal care package most countries, daily IFA supplementation is a key intervention. The World Health Organization (WHO) recommends daily oral IFA supplementation in areas where anemia prevalence rates are above 20 percent and weekly IFA supplementation in areas where anemia is 20 or below (see Table 5).

Table 5: IFA Supplementation Recommendations for Pregnant Women

Anemia Prevalence among Pregnant Women Recommendation
<20% 120 mg iron + 2,800 mcg folic acid weekly
20-40% 30-60 mg iron + 40 mcg folic acid daily
>40% 60 mg iron + 40 mcg folic acid daily

Source: WHO 2016b

IFA supplementation should begin as early as possible in a pregnancy and continue throughout. If a woman is diagnosed with anemia during her pregnancy, her iron dose should be increased to 120 mg daily until her hemoglobin concentration is normal (110 g/L or higher).

Low doses of folic acid—40 mcg daily or 2,800 mcg weekly—combined with iron can be given in combination with sulfadoxine-pyrimethamine to prevent malaria during pregnancy (see Intermittent Preventive Treatment during Pregnancy section) (Roll Back Malaria Partnership 2015; Maternal and Child Survival Program 2015). It is important to note that when providing IFA supplementation in settings with endemic infections, such as malaria and hookworm, measures to prevent and treat these infections should be implemented (WHO 2016b).

Many countries provide IFA supplementation to pregnant women through facility-based antenatal care, but in several countries, especially where antenatal care coverage is low, IFA supplements may be provided through community-based programs (MCHIP 2011). IFA supplementation for women of reproductive age (including adolescents) often relies on a community-based or other non-facility-based distribution model.

A barrier analyses on IFA supplementation consumption, while usually not nationally representative, can provide important insight into a program’s strengths and weaknesses, such as difficulties with the supply chain or poor distributor counseling skills (Sununtnasuk, D’Agostino, and Fiedler 2015). Quality of interpersonal counseling, and how side effects are addressed by health care providers, can also affect the implementation and effectiveness of an IFA supplementation intervention. Concerns about side effects are one main reason for non-compliance with IFA supplements among pregnant women; this may point to possible programmatic solutions, such as increasing women’s and communities’ awareness of the importance of supplements (Sadore, Gebretsadik, and Hussen 2015).

Measurement and data sources

Population-based surveys typically report the percentage of women with a live birth in the two to five years before the survey who received and took IFA supplementation during their most recent pregnancy. Surveys usually report means and medians, in addition to categorizing responses by the number of supplements consumed: any IFA supplements, less than 60, 60–89, or more than 90. Because antenatal care is typically the main platform for IFA supplement distribution for pregnant women, survey questions on antenatal care attendance and timing of the first antenatal care visit can provide information on the use of this platform to deliver IFA supplementation. Also, some surveys now ask women of reproductive age about their consumption of IFA supplements.

Surveys that collect information related to coverage of IFA supplementation include—

  • Demographic and Health Surveys
  • Multiple Indicator Cluster Surveys
  • National Micronutrient Surveys
  • Knowledge, Practice, and Coverage Surveys
  • other research or evaluation activities.

Health monitoring information systems usually include information about the distribution of IFA supplements to pregnant women, because they are one service that is supposed to be provided during antenatal care (Dwivedi et al. 2014).

Methodological issues

  • Coverage of IFA supplementation is not the same as adherence—and adherence to the correct dosing regimen is necessary to reach the intended impact. Most data sources report on IFA distribution, but women may not adhere to the dosage recommendations after they receive the supplements. Adherence intake is a challenge to measure and it may not be easily captured by the data outside year-end reports or research studies aimed at assessing coverage and adherence.
  • Pregnant women are supposed to take the supplement daily, beginning early in the pregnancy, but it can be difficult to find information on timing. Usually, timing of the first antenatal care visit is used as a proxy for beginning IFA supplementation, but this assumes that women do not have access to IFA supplementation earlier in the pregnancy.
  • Current routine data systems probably only capture IFA supplementation for pregnant women, while most systems do not collect data on supplementation for women of reproductive age, including adolescents.
  • Understanding antenatal care visits is helpful for interpreting data regarding IFA supplementation for pregnant women. Many countries, however, do not consistently record or report these data, complicating efforts to explain coverage of antenatal care services (Dwivedi et al. 2014).